Clinical UM Guideline
|Guideline #:||CG-REHAB-03||Current Effective Date:||10/14/2014|
|Status:||Reviewed||Last Review Date:||08/14/2014|
This document addresses the use of pulmonary rehabilitation for the treatment of various lung conditions.
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:
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.
The following codes for treatments and procedures applicable to this document are included below for informational purposes. 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.
|G0237||Therapeutic procedures to increase strength or endurance of respiratory muscles, face to face, one on one, each 15 minutes (includes monitoring)|
|G0238||Therapeutic procedures to improve respiratory function, other than described by G0237, one on one, face to face, per 15 minutes (includes monitoring)|
|G0239||Therapeutic procedures to improve respiratory function or increase strength or endurance of respiratory muscles, two or more individuals (includes monitoring)|
|G0302-G0304||Preoperative pulmonary surgery services for preparation for LVRS [includes codes G0302, G0303, G0304]|
|G0305||Post discharge pulmonary surgery services after LVRS, minimum of 6 days of services|
|G0424||Pulmonary rehabilitation, including exercise (includes monitoring), one hour, per session, up to two sessions per day|
|S9473||Pulmonary rehabilitation program, non-physician provider, per diem|
|ICD-9 Diagnosis||[For dates of service prior to 10/01/2015]|
|ICD-10 Diagnosis||[For dates of service on or after 10/01/2015]|
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:
Several studies have demonstrated important benefits of PR including reducing dyspnea (shortness of breath) and improving exercise capacity, total energy expenditure, and quality of life (QOL) (Dodd, 2012; Egan, 2012; McFarland, 2012; Mandal, 2012). A number of studies 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 non-significant trend for PR to increase 5-year survival. Mandal and colleagues conducted a pilot randomized controlled trial (RCT) with 30 subjects with non-cystic fibrosis bronchiectasis (2012). The primary outcome measure was the incremental shuttle walking test (ISWT). Study authors reported no benefit for subjects in the control group, who received chest physiotherapy only, at the end of 8 weeks of therapy, or at 20 weeks post-therapy. Subjects in the experimental group, who received chest physiotherapy in conjunction with PR, demonstrated significant benefits (relative to baseline values) on 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 following the last training session, the experimental group also showed continued and significant improvement (relative to baseline values) for ISWT (p=0.04) and EWT (p=0.003). LCQ and SGRQ also were significantly improved compared with baseline (p<0.001 for both measures). Limitations of this study include the lack of statistical comparisons between treatment and control groups, small study population, lack of blinding, and lack of clinically relevant primary outcome measures. Additional well-designed RCTs are necessary to confirm these initial findings.
Frequency and duration of the program may vary according to the individual's needs. It is not uncommon for the person to receive therapy 3 times per week for 4 to 6 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 (HR-QOL) measures.
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
Chronic Obstructive Pulmonary Disease
Chronic Respiratory Impairment
Lung Volume Reduction
|Reviewed||08/14/2014||Medical Policy & Technology Assessment (MPTAC) review. No change to position statement. Updated Discussion/General Information and References sections.|
|Reviewed||08/08/2013||MPTAC review. No change to position statement. Updated reference section.|
|Reviewed||08/09/2012||MPTAC review. No change to position statement. Updated reference section.|
|Reviewed||08/18/2011||MPTAC review. No change to position statement.|
|Reviewed||08/19/2010||MPTAC review. No change to position statement.|
|01/01/2010||Updated coding section with 01/01/2010 HCPCS changes.|
|Reviewed||08/27/2009||MPTAC review. No change to position statement.|
|Reviewed||08/28/2008||MPTAC review. No change to position statement.|
|11/05/2007||Updated Reference section. Added 2007 ACCP/AACVPR recommendations.|
|Revised||08/23/2007||MPTAC review. Removed "superimposed cardiac disease" from medically necessary section. Updated reference section. Coding updated; removed HCPCS G0110-G0116 deleted 12/31/2005.|
|Reviewed||09/14/2006||MPTAC review. No change to position statement. Updated references.|
|11/21/2005||Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).|
|Revised||09/22/2005||MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.|
|Pre-Merger Organizations||Last Review |
|Anthem MidWest||RA-010||Pulmonary Rehab in Acute Inpatient Rehabilitation Setting|
|Anthem West||UMR.016||Pulmonary Rehabilitation|
|Anthem SouthEast||Memo 1121||Pulmonary Rehabilitation|
|Anthem New Hampshire||Pulmonary Rehabilitation|
|WellPoint Health Networks, Inc.||04/28/2005||2.05.10||Pulmonary Rehabilitation (Outpatient)|