Clinical UM Guideline


Subject:  Pulmonary Rehabilitation
Guideline #:  CG-REHAB-03Current Effective Date:  10/08/2013
Status:ReviewedLast Review Date:  08/08/2013

Description

This document addresses the use of pulmonary rehabilitation for the treatment of various lung conditions.

Clinical Indications

Medically Necessary:

Pulmonary rehabilitation (PR) is considered medically necessary in select individuals with chronic respiratory impairment who, despite optimal medical management, are experiencing disabling dyspnea associated with a restriction in ordinary activities and significantly impaired quality of life.  Candidates must also be motivated to participate in a PR program.  Individuals meeting these criteria may include those suffering with any of the following:

Pulmonary rehabilitation (PR) is considered medically necessary as part of the preparation and recovery from surgical interventions such as:

Comorbidities that may cause an individual to be excluded from PR generally fall into two categories:

  1. Conditions that may interfere with the individual undergoing the rehabilitative process, including but not limited to:
    • Advanced arthritis; or
    • Disruptive behavior; or
    • Inability to learn.
  2. Conditions that may place the individual at undue risk during exercise training, including but not limited to:
    • Recent myocardial infarction; or
    • Severe pulmonary hypertension; or
    • Unstable angina.

Not Medically Necessary:

Repeat pulmonary rehabilitation (PR) programs are considered not medically necessary.  However, exceptions may be made for individuals undergoing a second PR program in connection with lung transplantation or lung volume reduction surgery when medical necessity criteria are met.

Pulmonary rehabilitation provided in the inpatient setting in and of itself is considered not medically necessary.

Place of Service/Duration

Place of Service:  Ambulatory/Outpatient
Duration: Frequency and duration of the program may vary according to the individual's needs. It is not uncommon for the individual to receive therapy three times per week for four to six weeks.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  A draft of future ICD-10 Coding (effective 10/01/2014) related to this document, as it might look today, is included below for your reference.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

HCPCS 
G0237Therapeutic procedures to increase strength or endurance of respiratory muscles, face to face, one on one, each 15 minutes (includes monitoring)
G0238Therapeutic procedures to improve respiratory function, other than described by G0237, one on one, face to face, per 15 minutes (includes monitoring)
G0239Therapeutic procedures to improve respiratory function or increase strength or endurance of respiratory muscles, two or more individuals (includes monitoring)
G0302-G0304Preoperative pulmonary surgery services for preparation for LVRS [includes codes G0302, G0303, G0304]
G0305Post discharge pulmonary surgery services after LVRS, minimum of 6 days of services
G0424Pulmonary rehabilitation, including exercise (includes monitoring), one hour, per session, up to two sessions per day
S9473Pulmonary rehabilitation program, non-physician provider, per diem
  
ICD-9 Diagnosis 
 All diagnoses
  
ICD-10 DiagnosisICD-10-CM draft codes; effective 10/01/2014
 All diagnoses
  
Discussion/General Information

Pulmonary rehabilitation (PR) is an individually tailored multidisciplinary program of care for people with chronic respiratory impairment. The PR program combines an accurate diagnosis with therapy, emotional support and education to stabilize or reverse both the physio- and psychopathology of pulmonary disease.

The goal of PR is to:

Many studies have demonstrated important benefits of PR including reducing dyspnea (shortness of breath) and improving exercise capacity total energy expenditure, and quality of life (Dodd, 2012; Egan, 2012; McFarland, 2012; Mandal, 2012).  A number of reports have demonstrated that PR has also been associated with decreases in hospitalization rates and the overall utilization of medical resources.  A randomized trial conducted by Ries and colleagues (2005) demonstrated a trend for PR to increase five year survival.  Mandal and colleagues conducted a randomized controlled trial with thirty subjects with non cystic fibrosis bronchiectasis (2012). They reported no benefit in the control group, which received chest physiotherapy only, at the end of 8 weeks of therapy, or at 20 weeks post-therapy. The experimental group, which received chest physiotherapy in conjunction with PR, demonstrated significant benefits on the incremental shuttle walk test (ISWT) (p=0.03), endurance walk test (EWT) (p=0.01), Leicester Cough Questionnaire (LCQ) (p<0.001) and St. George's Respiratory Questionnaire (SGRQ) (p<0.001).  At 12 weeks post end of training, the experimental group showed continued improvement in ISWT (p=0.04) and EWT (p=0.003).  LCQ also was improved (p<0.001) and SGRQ (p<0.001).  A larger randomized clinical trial (RCT) is needed to examine this issue definitively.

Frequency and duration of the program may vary according to the individual's needs.  It is not uncommon for the person to receive therapy three times per week for four to six weeks.

The permanence of outcomes achieved by PR appears to be more related to the structure and duration of the supervised maintenance component of the program than the intensity of the program.  The long-term outcome data are somewhat limited in this respect.  To achieve sustained results, it is important that the person continues with the at-home regimen outlined in the PR program.

There is currently no evidence that repeat pulmonary rehabilitation programs result in additive long term benefits in terms of dyspnea, exercise tolerance or health related quality of life measures.

References

Peer Reviewed Publications:

  1. Carr SJ, Hill K, Brooks D, Goldstein RS. Pulmonary rehabilitation after acute exacerbation of chronic obstructive pulmonary disease in patients who previously completed a pulmonary rehabilitation program. J Cardiopulm Rehabil Prev. 2009; 29(5):318-324.
  2. Di Meo F, Pedone C, Lubich S, et al. Age does not hamper the response to pulmonary rehabilitation of COPD patients. Age Ageing. 2008; 37(5):530-535.
  3. Dodd JW, Marns PL, Clark AL, et al. The COPD Assessment Test (CAT): short- and medium-term response to pulmonary rehabilitation. COPD. 2012; 9(4):390-394.
  4. Egan C, Deering BM, Blake C, et al. Short term and long term effects of pulmonary rehabilitation on physical activity in COPD. Respir Med. 2012; 106(12):1671-1679.
  5. Ferguson GT. Recommendations for the management of COPD. Chest. 2000; 117(2 Suppl):23S-28S.
  6. Foglio K, Bianchi L, Ambrosino N.  Is it really useful to repeat outpatient pulmonary rehabilitation programs in patients with chronic airway obstruction? A 2-year controlled study. Chest. 2001; 119(6):1696-1704.
  7. Griffiths TL, Phillips CJ, Davies S, et al. Cost effectiveness of an outpatient multidisciplinary pulmonary rehabilitation programme. Thorax. 2001; 56(10):779-784.
  8. Kaplan RM, Ries AL, Reilly J, Mohsenifar Z. Measurement of health-related quality of life in the national emphysema treatment trial.  Chest. 2004; 126(3):781-789.
  9. Ketelaars CA, Abu-Saad HH, Schlosser MA, et al. Long-term outcome of pulmonary rehabilitation in patients with COPD. Chest. 1997; 112(2):363-369.
  10. Mahler DA. Pulmonary rehabilitation. Chest. 1998; 113(4 Suppl):263S-268S.
  11. Maltais F, Bourbeau J, Shapiro S, et al. Effects of home-based pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: a randomized trial. Ann Intern Med. 2008; 149(12):869-878.
  12. Mandal P, Sidhu MK, Kope L, et al.  A pilot study of pulmonary rehabilitation and chest physiotherapy versus chest physiotherapy alone in bronchiectasis. Respir Med. 2012; 106(12):1647-1654.
  13. McFarland C, Willson D, Sloan J, Coultas D. A randomized trial comparing 2 types of in-home rehabilitation for chronic obstructive pulmonary disease: a pilot study. J Geriatr Phys Ther. 2012; 35(3):132-139.
  14. Ries AL, Make BJ, Lee SM, et al.; National Emphysema Treatment Trial Research Group. The effects of pulmonary rehabilitation in the national emphysema treatment trial. Chest. 2005; 128(6):3799-3809.
  15. San Pedro GS.  Pulmonary rehabilitation for the patient with severe chronic obstructive pulmonary disease.  Am J Med Sci. 1999; 318(2):99-102.
  16. von Leupoldt A, Hahn E, Taube K, et al. Effects of 3-week outpatient pulmonary rehabilitation on exercise capacity, dyspnea, and quality of life in COPD. Lung. 2008; 186(6):387-391.
  17. Waterhouse JC, Walters SJ, Oluboyede Y, Lawson RA. A randomised 2 x 2 trial of community versus hospital pulmonary rehabilitation, followed by telephone or conventional follow-up. Health Technol Assess. 2010; 14(6):i-v, vii-xi, 1-140.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Agency for Healthcare Quality and Research.  Pulmonary rehabilitation for COPD and other lung diseases. November 21, 2006.  Available at: http://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads/id43TA.pdf. Accessed on June 11, 2013.
  2. American Association for Respiratory Care (AARC). AARC clinical practice guideline: pulmonary rehabilitation. Dallas (TX): American Association for Respiratory Care (AARC); 2002.  Available at http://www.rcjournal.com/cpgs/prcpg.html. Accessed on June 11, 2013.
  3. Centers for Medicare and Medicaid Services. National Coverage Determination. Available at http://www.cms.hhs.gov/mcd/index_list.asp?list_type=ncd. Accessed on June 11, 2013.
    • Lung Volume Reduction Surgery (Reduction Pneumoplasty). NCD #240.1.  Effective November 17, 2005.
    • Pulmonary Rehabilitation. NCD #240.8. Effective September 25, 2007.
  4. Lacasse Y, Goldstein R, Lasserson TJ, Martin S. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD003793.
  5. Nici L, Donner C, Woulters E, et al. American Thoracic Society/European Respiratory Society Statement on Pulmonary Rehabilitation. Am J Respir Crit Care Med. 2006; 173(12):1390-1413. Available at: http://www.thoracic.org/statements/resources/respiratory-disease-adults/atserspr0606.pdf. Accessed on June 11, 2013.
  6. Parshall MB, Schwartzstein RM, Adams L, et al.; American Thoracic Society Committee on Dyspnea. An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. Am J Respir Crit Care Med. 2012; 185(4):435-452.
  7. Puhan MA, Gimeno-Santos E, Scharplatz M, et al. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2011, Issue 10. Art. No.: CD005305.
  8. Qaseem A, Wilt TJ, Weinberger SE, et al.; American College of Physicians; American College of Chest Physicians; American Thoracic Society; European Respiratory Society. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med. 2011; 155(3):179-191.
  9. Ries AL, Bauldoff GS, Carlin BW, et al.  Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines. Chest. 2007; 131(5 Suppl):4S-42S.
Index

Asthma
Bronchiectasis
Chronic Bronchitis
Chronic Obstructive Pulmonary Disease
Chronic Respiratory Impairment
Cystic Fibrosis
Emphysema
Lung Transplantation
Lung Volume Reduction
Post-Polio Syndrome
Pulmonary Rehabilitation

History
StatusDateAction
Reviewed08/08/2013Medical Policy & Technology Assessment (MPTAC) review. No change to position statement. Updated reference section.
Reviewed08/09/2012MPTAC review. No change to position statement. Updated reference section.
Reviewed08/18/2011MPTAC review. No change to position statement.
Reviewed08/19/2010MPTAC review. No change to position statement.
 01/01/2010Updated coding section with 01/01/2010 HCPCS changes.
Reviewed08/27/2009MPTAC review. No change to position statement.
Reviewed08/28/2008MPTAC review. No change to position statement.
 11/05/2007Updated Reference section.  Added 2007 ACCP/AACVPR recommendations.
Revised08/23/2007MPTAC review. Removed "superimposed cardiac disease" from medically necessary section. Updated reference section.  Coding updated; removed HCPCS G0110-G0116 deleted 12/31/2005.
Reviewed09/14/2006MPTAC review. No change to position statement.  Updated references.
 11/21/2005Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).
Revised09/22/2005MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization. 
Pre-Merger OrganizationsLast Review DateDocument NumberTitle

Anthem MidWest

 

 RA-010Pulmonary Rehab in Acute Inpatient Rehabilitation Setting
Anthem West UMR.016Pulmonary Rehabilitation
Anthem SouthEast Memo 1121Pulmonary Rehabilitation
Anthem New Hampshire  Pulmonary Rehabilitation
WellPoint Health Networks, Inc.04/28/20052.05.10Pulmonary Rehabilitation (Outpatient)