This document addresses the use of pulmonary rehabilitation for the treatment of various lung conditions.
- Pulmonary rehabilitation (PR) is considered medically necessary in individuals who meet the following criteria:
- Individual is free from the following comorbidities:
- 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; and
- 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.
AND meet the following criteria from B OR C:
- Individual with chronic respiratory impairment that, despite optimal medical management, results in disabling dyspnea associated with a restriction in ordinary activities and significant impairment in 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:
- Chronic obstructive pulmonary disease such as:
- Asthma; or
- Bronchiectasis; or
- Chronic bronchitis; or
- Cystic fibrosis; or
- Emphysema; or
- Restrictive diseases such as:
- Chest wall disease; or
- Interstitial disease; or
- Post-polio syndrome; or
- Selected neuromuscular disorders; or
- Thoracic cage abnormalities; or
- Stable lung cancer;
- Individual is preparing for OR recovering from surgical interventions such as:
- Lung transplantation; or
- Lung volume reduction surgery; or
- Post-operative states (for example, thoracic or abdominal surgery).
- Repeat PR programs may be considered medically necessary for individuals undergoing a second PR program in connection with lung transplantation or lung volume reduction surgery when medical necessity criteria for PR are met.
Not Medically Necessary:
PR provided in the inpatient setting is considered not medically necessary when medical necessity criteria for PR are not met.
|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 3 times per week for 4 to 6 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-10 Diagnosis||[For dates of service on or after 10/01/2015]|
| ||All diagnoses|
| || |
|ICD-9 Diagnosis||[For dates of service prior to 10/01/2015]|
| ||All diagnoses|
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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:
- Restore the individual to the highest possible level of independent function.
- Educate the individual and significant others about the disease, treatment options and coping strategies.
- Encourage individuals to be actively involved in providing for their own healthcare and to be more independent in activities of daily living (ADL).
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; Mandal, 2012; McFarland, 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:
- Busby AK, Reese RL, Simon SR. Pulmonary rehabilitation maintenance interventions: a systematic review. Am J Health Behav. 2014; 38(3):321-330.
- 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.
- Cejudo P, López-Márquez I, López-Campos JL, et al. Exercise training in patients with chronic respiratory failure due to kyphoscoliosis: a randomized controlled trial. Respir Care. 2014; 59(3):375-382.
- 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.
- 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.
- 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.
- Ferguson GT. Recommendations for the management of COPD. Chest. 2000; 117(2 Suppl):23S-28S.
- 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.
- Griffiths TL, Phillips CJ, Davies S, et al. Cost effectiveness of an outpatient multidisciplinary pulmonary rehabilitation programme. Thorax. 2001; 56(10):779-784.
- 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.
- 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.
- Mahler DA. Pulmonary rehabilitation. Chest. 1998; 113(4 Suppl):263S-268S.
- 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.
- 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.
- 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.
- Morano MT, Mesquita R, Da Silva GP, et al. Comparison of the effects of pulmonary rehabilitation with chest physical therapy on the levels of fibrinogen and albumin in patients with lung cancer awaiting lung resection: a randomized clinical trial. BMC Pulm Med. 2014; 14:121.
- 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.
- Salhi B, Huysse W, Van Maele G, et al. The effect of radical treatment and rehabilitation on muscle mass and strength: a randomized trial in stages I-III lung cancer patients. Lung Cancer. 2014; 84(1):56-61.
- San Pedro GS. Pulmonary rehabilitation for the patient with severe chronic obstructive pulmonary disease. Am J Med Sci. 1999; 318(2):99-102.
- 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.
- 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:
- 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 23, 2015.
- 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 23, 2015.
- American Thoracic Society. Guidelines for Health Professionals:
- 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 23, 2015.
- Lung Volume Reduction Surgery (Reduction Pneumoplasty). NCD #240.1. Effective November 17, 2005.
- Pulmonary Rehabilitation. NCD #240.8. Effective September 25, 2007.
- Collins EG, Bauldoff G, Carlin B, et al. Clinical competency guidelines for pulmonary rehabilitation professionals: position statement of the American Association of Cardiovascular and Pulmonary Rehabilitation. J Cardiopulm Rehabil Prev. 2014; 34(5):291-302.
- Dowman L, Hill CJ, Holland AE. Pulmonary rehabilitation for interstitial lung disease. Cochrane Database Syst Rev. 2014;10:CD006322.
- McCarthy B, Casey D, Devane D et al.. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2015;(2):CD003793.
- 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 23, 2015.
- 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.
- Puhan MA, Gimeno-Santos E, Scharplatz M, et al. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Data Syst Rev. 2011;(10):CD005305.
- 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.
- 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.
Chronic Obstructive Pulmonary Disease
Chronic Respiratory Impairment
Lung Volume Reduction
|Revised||08/06/2015||Medical Policy & Technology Assessment (MPTAC) review. Reformatted criteria. Updated Background/Overview and References sections.|
|Reviewed||08/14/2014||MPTAC review. Updated Discussion/General Information and References sections.|
|Reviewed||08/08/2013||MPTAC review. Updated reference section.|
|Reviewed||08/09/2012||MPTAC review. Updated reference section.|
| ||01/01/2010||Updated coding section with 01/01/2010 HCPCS changes.|
| ||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. 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 Date||Document Number||Title|
| ||RA-010||Pulmonary Rehab in Acute Inpatient Rehabilitation|
|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)|