Clinical UM Guideline

This document addresses cardiac rehabilitation (CR) services that are provided on an outpatient basis during the immediate post-discharge period and are considered Phase II cardiac rehabilitation programs (see Discussion/General Information section for further information related to the phases of Cardiac Rehabilitation Programs). Phase I cardiac rehabilitation programs are done in the inpatient setting and are out of scope for this document.

Note: For a high-level overview of this document, please see “Summary for Members and Families” below.

Medically Necessary:

Phase II cardiac rehabilitation is considered medically necessary when individually prescribed by a physician and the following criteria are met:

1. Cardiac rehabilitation is initiated within 12 months of ANY of the following:
   1. Acute myocardial infarction (MI); or
   2. Coronary artery bypass grafting (CABG); or
   3. Heart transplantation; or
   4. Percutaneous coronary intervention (that is, atherectomy, angioplasty, stenting); or
   5. Survivor of sudden cardiac death; or
   6. Survivor of sustained ventricular tachycardia or fibrillation; or
   7. Valve replacement or repair; or
   8. New York Heart Association (NYHA) Class II to IV congestive heart failure (CHF) that is interfering with the ability to perform age-related activities of daily living; or
   9. Coronary artery disease (CAD) with chronic stable angina pectoris that has failed to respond to pharmacotherapy and is interfering with the ability to perform age-related activities of daily living;
      and
2. The individual does not have an absolute contraindication to cardiac rehabilitation (examples include: unstable angina, overt cardiac failure, dangerous arrhythmias, dissecting aneurysm, myocarditis, acute pericarditis, severe obstruction of the left ventricular outflow tract, severe hypertension, exertional hypotension or syncope, uncontrolled diabetes mellitus, severe orthopedic limitations, and recent systemic or pulmonary embolus).

Not Medically Necessary:

The following are considered not medically necessary:

1. When the criteria above are not met;
2. Phase III cardiac rehabilitation programs, or self-directed, self-controlled or monitored exercise programs;
3. Phase IV cardiac rehabilitation programs or maintenance therapy that may be safely carried out without medical supervision;
4. Cardiac rehabilitation when used in a preventive or prophylactic way, such as for angina, hypertension, or diabetes.

This document describes clinical studies and expert recommendations, and explains whether cardiac rehabilitation services are clinically appropriate. The following summary does not replace the medical necessity criteria or other information in this document. The summary may not contain all of the relevant criteria or information. This summary is not medical advice. Please check with your healthcare provider for any advice about your health.

Key Information

Cardiac rehabilitation (CR) is a type of treatment program that helps people recover and stay healthy after serious heart problems or treatments. It usually starts soon after a person leaves the hospital. The program includes supervised exercise, help with diet and stress, and support for quitting smoking or managing conditions like diabetes. It also teaches people how to safely get active again and avoid future heart issues. There are four stages of CR. The first happens in the hospital right after a heart event. The second stage is outpatient care that lasts up to 12 weeks and includes supervised exercise and education. The third and fourth stages focus on long-term health and are usually done at home or in the community. Exercise training is one of the most important parts of CR . It can help people move better, feel stronger, and improve heart function. The benefits vary depending on the person and how much they stick with the program, but research shows it can help reduce hospital visits and may help people live longer.

What the Studies Show

Studies show that cardiac CR improves health in several ways. People who take part in CR after heart surgery or heart attacks often have fewer hospital visits and may live longer. For example, people who participated in CR after a heart procedure may be less likely to die or experience new blockage of heart arteries compared to people who did not. Exercise training in these programs improves how much oxygen the body can use, which helps people exercise longer with less strain on the heart.

However, some studies found only small or unclear improvements in survival or hospital visits, especially for people with heart failure or those using heart pumps (called ventricular assist devices). In these cases, CR programs helped with physical fitness but didn’t clearly improve quality of life or long-term survival.

Is this clinically appropriate?

This treatment is considered appropriate because many studies show it can improve recovery and lower the chance of future heart problems. It helps people build strength, speeds up return to daily activities, and helps manage heart risks. Some benefits, such as fewer hospital stays and better exercise ability, have been clearly shown in studies. Other possible benefits, like improved survival or quality of life, may depend on the person’s health and how closely they follow the program.

(Return to Description)

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.

When services may be Medically Necessary when criteria are met:

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met, or when the code describes a procedure or situation designated in the Clinical Indications section as not medically necessary.

Summary

Cardiac rehabilitation (CR) is a comprehensive, multidisciplinary intervention designed to improve functional capacity, reduce cardiovascular risk, and support long-term secondary prevention. As defined by the American Heart Association (AHA) and the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR), CR includes structured exercise training alongside risk factor modification, education, and psychosocial support, with consistent evidence demonstrating improvements in exercise capacity and selected clinical outcomes across cardiac populations.

Evidence supporting CR varies by condition but is generally favorable. In individuals with heart failure with reduced ejection fraction, a large randomized controlled trial (O’Connor, 2009) demonstrated that exercise-based CR is safe and may provide modest clinical benefit, although statistically significant reductions in mortality or hospitalization were not observed in the primary analysis. Observational evidence in individuals undergoing percutaneous coronary intervention (Goel, 2011) suggests substantial reductions in long-term mortality among those who participate in CR, though such findings are subject to selection bias and were not associated with reductions in myocardial infarction or repeat revascularization. Additional studies (Lee, 2014) and systematic reviews indicate improvements in surrogate outcomes such as exercise capacity, risk factor profiles, and possibly short-term reductions in hospitalizations, although effects on mortality and other hard clinical endpoints are inconsistent or of variable certainty across populations. Overall, the evidence supports CR as a safe intervention with functional and potential clinical benefits, while also highlighting variability in the strength of outcome data depending on the population studied.

The structure and intensity of CR are appropriately tailored based on risk stratification, which incorporates measures of functional capacity (e.g., METs), ventricular function, ischemic burden, and arrhythmia risk. This framework supports the differentiation of high-, intermediate-, and low-risk individuals and informs the level of supervision, monitoring (e.g., telemetry), and duration of therapy required, forming the basis for criteria addressing frequency and duration of services.

With respect to pre-rehabilitation exercise stress testing, earlier guidance recommended routine symptom-limited exercise testing prior to CR to assess ischemia, establish baseline functional capacity, and guide exercise prescription. However, more recent expert statements and reviews recognize that this approach is not necessary for all individuals. In clinically stable individuals, particularly those initiating low-intensity exercise, CR can be safely started without prior stress testing, with functional capacity and tolerance assessed during early supervised sessions. This shift reflects the limited incremental value of routine testing in all participants and the potential for such requirements to delay initiation and reduce participation in CR. Accordingly, current criteria support a more selective, individualized approach to stress testing rather than a universal requirement.

In summary, the criteria are supported by evidence demonstrating that CR improves functional outcomes and is safe across a range of cardiac conditions, with risk stratification guiding program intensity and monitoring. The approach to pre-rehabilitation stress testing reflects contemporary evidence and expert consensus favoring selective use to avoid unnecessary barriers to timely CR initiation.

Discussion

Over the few decades, risk factor modification programs for individuals with cardiac conditions have evolved into a comprehensive management strategy. The American Heart Association (AHA) and the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) define CR programs as, “Coordinated, multifaceted interventions designed to optimize a cardiac patient’s physical, psychological, and social functioning, in addition to stabilizing, slowing, or even reversing the progression of the underlying atherosclerotic processes, thereby reducing morbidity and mortality” (Leon, 2005). Interventions include, “Baseline patient assessments, nutritional counseling, aggressive risk factor management, (i.e., lipids, hypertension, weight, diabetes, and smoking), psychosocial and vocational counseling, and physical activity counseling and exercise training, in addition to the appropriate use of cardioprotective drugs”.

Role of pre-rehabilitation cardiac stress testing

A 2007 scientific statement from the AHA and the AACVPR (Balady, 2007) addresses the core components of CR /secondary prevention programs and states the following:

Symptom-limited exercise testing is strongly recommended prior to participation in an exercise-based CR program. The evaluation may be repeated as changes in clinical condition warrant. Test parameters should include assessment of heart rate and rhythm, signs, symptoms, ST-segment changes, hemodynamics, perceived exertion, and exercise capacity. On the basis of patient assessment and the exercise test if performed, it is recommended to risk stratify the patient to determine the level of supervision and monitoring required during exercise training.

A 2013 scientific statement from the AHA indicates that, although symptom-limited exercise testing is generally recommended before initiating cardiac rehabilitation to establish baseline functional capacity, guide exercise prescription, and assess for ischemia or arrhythmias, it is not an absolute requirement in all individuals (Fletcher, 2013). In clinically stable individuals, particularly those beginning with low-intensity exercise, cardiac rehabilitation may be initiated without prior stress testing, with early supervised sessions serving to assess functional capacity and tolerance. This approach reflects the limited incremental value of routine testing in all participants and avoids unnecessary barriers to timely initiation of rehabilitation, while maintaining safety through clinical evaluation and ongoing monitoring during exercise training.

A 2016 review article by Reeves and colleagues noted that symptom-limited exercise testing was historically considered standard prior to initiating cardiac rehabilitation (CR), primarily to assess for residual ischemia and guide safe exercise prescription. However, with advances in revascularization and contemporary medical therapy, many individuals are now clinically stable and able to begin low-intensity exercise shortly after discharge without prior testing. The authors emphasize that routine pre-CR stress testing may introduce unnecessary delays and other barriers to enrollment, potentially limiting participation. While exercise testing remains useful for individualized risk stratification and exercise prescription, the evidence supports a more selective, patient-centered approach rather than requiring stress testing for all individuals before initiating CR.

Role of cardiac rehabilitation for heart failure with reduced ejection fraction

O’Connor (2009) conducted a multicenter, randomized controlled trial enrolled 2331 medically stable individuals with heart failure (HF) and reduced ejection fraction assigned either to usual care plus aerobic exercise training (36 supervised sessions followed by home-based training [traditional CR model]) or usual care alone. The study’s primary endpoint was a composite of all-cause mortality or hospitalization and prespecified secondary endpoints of all-cause mortality, cardiovascular mortality or hospitalization. At a median follow-up of approximately 30 months, there was no statistically significant difference between groups for the primary outcome (65% vs. 68%; hazard ratio [HR], 0.93; 95% confidence interval [CI], 0.84-1.02; p=0.13). Similarly, there were no significant differences in secondary outcomes including all-cause mortality or cardiovascular mortality or hospitalization. In prespecified analyses adjusted for prognostic baseline characteristics, modest reductions were observed for the primary outcome (HR, 0.89; 95% CI, 0.81-0.99) and for cardiovascular mortality or heart failure hospitalization (HR, 0.85; 95% CI, 0.74-0.99). However, these findings were not observed in the primary unadjusted analysis. Overall, the trial demonstrates that exercise-based cardiac rehabilitation is safe and may be associated with modest improvements in clinical outcomes, but did not show a statistically significant reduction in mortality or hospitalization in the primary analysis.

Role of cardiac rehabilitation for individuals with coronary artery disease

Goel (2011) conducted a retrospective analysis of a prospectively-collected registry including 2395 individuals  who underwent percutaneous coronary intervention (PCI) between 1994 and 2008. Of these 2395 individuals, 964 enrolled in CR within 3 months of PCI. Median follow-up was 6.3 years. During that time, there were 503 deaths, of which 199 were due to cardiovascular disease. Revascularization was required in 755 individuals and 394 individuals had subsequent myocardial infarction. Using propensity score-based methods to adjust for baseline differences, CR participation was associated with a 45% to 47% decrease in mortality compared to nonparticipation. However, CR participation was not associated with reductions in subsequent myocardial infarction or repeat revascularization.

A study by Lee (2014) reported results for 576 individuals who received drug-eluting stent implantation for coronary artery disease who were then referred for CR. A total of 288 participants successfully completed the CR program. The primary endpoint was in-stent luminal loss at a 9-month angiographic follow-up. Those who completed the CR program had a 35% less in-stent luminal loss when compared to those who didn’t complete the CR. Those in the CR group also showed an improvement in overall risk factors including current smoking, biochemical profiles, depression, obesity and exercise capacity.

A Cochrane review investigating the effect of exercise-based CR on individuals with HF included 44 studies which were comprised of 5783 participants (Long, 2024). All studies included a ‘no formal exercise’ training intervention comparator, although a wide range of comparators were seen across studies (such as, education, psychological intervention or usual medical care alone). The review concluded that there were probable benefits of exercise-based CR, including a reduction in the risk of overall hospital admissions in the short term, as well as a potential reduction in HF-related admissions. The effect of exercise-based rehabilitation on health-related quality of life (QoL) for individuals with HF remains uncertain due to ‘very low-quality evidence’ as rated by the GRADE method. Authors conclude that exercise-based rehabilitation may make little or no difference in all-cause mortality in the short-term (less than 12 months; risk ratio [RR], 0.89, 95% CI, 0.66-1.2) but may impact all-cause mortality in the longer-term (RR, 0.88, 95% CI, 0.75 to 1.02; high-quality evidence) and that further evidence is needed to better elucidate the effects of exercise-based CR on individuals with HF in both the long and short-term.

Another Cochrane review evaluating exercise-based CR in individuals with implantable ventricular assist devices (VADs) identified two randomized studies with a total of 40 participants (Yamamoto, 2018). In the studies, exercise-based CR consisted of aerobic training, resistance training, or both, performed three times per week for 6 to 8 weeks. Exercise intensity was prescribed at approximately 50% of oxygen consumption (VO2) reserve, or 60% to 80% of heart rate reserve. A pooled analysis demonstrated a difference in quality of life favoring CR (standardized mean difference 0.88, 95% CI, -0.12-1.88); however, the confidence interval was wide and crossed zero, indicating substantial imprecision and uncertainty in the estimate.

The overall quality of evidence was rated as very low using GRADE due to small sample size, risk of bias (including lack of blinding), indirectness, and imprecision. No data was available for key clinical outcomes such as mortality, rehospitalization, or heart transplantation. The authors concluded that current evidence is insufficient to determine the safety or efficacy of exercise-based CR in individuals with implantable VADs.

A systematic review was conducted to summarize the current state of evidence related to the effects of exercise-based CR on the health-status of individuals diagnosed with stable angina (Long, 2019a). A total of 7 studies including a total of 581study participants met criteria for analysis. The effect of exercise-based CR on all-cause mortality (RR, 1.01, 95% CI, 0.18-5.67), acute myocardial infarction (RR, 0.33, 95% CI, 0.07-1.63) and cardiovascular-related hospital admissions (RR, 0.14, 95% CI, 0.02 to 1.1) relative to control were not determined to be statistically significant. Exercise-based CR was determined to have a moderately positive impact on exercise capacity (standard mean difference 0.45, 95% CI, 0.20 to 0.70), though this was based on low-quality evidence (GRADE method). There was limited and very low-quality evidence on the effect of exercise-based CR on health related QoL measures. The study’s authors concluded that exercise-based CR may improve short-term exercise capacity in individuals with stable angina but well-designed, randomized controlled clinical trials are needed to determine the impact on other outcomes including mortality, morbidity and QoL.

General background

Exercise training is the principal component of CR. Exercise can increase peak exercise capacity, which is usually expressed in METs (metabolic equivalents). This is the total oxygen requirement of the body, with 1 MET equal to 3.5 mL of oxygen consumed per kilogram of body weight per minute. Exercising skeletal muscles results in improved oxygen delivery and extraction. This, in turn, improves MET capacity by up to 10% to 50%, resulting in a decrease in the cardiovascular requirements of exercise and an increase in the amount of work that can be done before ischemia occurs. Although dynamic aerobic exercise is necessary to improve cardiovascular endurance, resistance exercise is becoming a useful adjunctive component of the exercise regimen as well. Resistance training should be included in the exercise program to minimize loss of muscle mass.

CR programs are generally divided into four phases (Thompson, 2007).

Phases of Cardiac Rehabilitation

Place of Service and Frequency/Duration

CR may be done in either the inpatient, ambulatory, or outpatient facility settings. This document specifically addresses the use of CR in the ambulatory and outpatient facility settings.

The frequency and duration of CR may vary according to several factors including the cardiac risk level of the individual being treated and the degree of exercise limitation present at baseline. Risk level is stratified and characterized in the following manner:

High Risk:
Individuals in the high-risk category may have ANY of the following:

• Exercise test limited to less than or equal to 5 metabolic equivalents (METS). (MET = a multiple of the resting energy expenditure, and is used as a means of estimating cardiac functional capacity. [1 MET = 3.5ml O2/kg body wt/min]); or
• Marked exercise-induced ischemia, as indicated by either anginal pain or 2 mm or more ST segment depression by ECG; or
• Severely depressed left ventricular function (ejection fraction less than 30%); or
• Resting complex ventricular arrhythmias; or
• Ventricular arrhythmias appearing or increasing with exercise or occurring in the recovery phase of stress testing; or
• Decrease in systolic blood pressure of greater than 15 mm Hg with exercise; or
• Recent myocardial infarction (less than 6 months) which was complicated by serious ventricular arrhythmias, cardiogenic shock, or congestive heart failure (CHF); or
• Survivor of sudden cardiac arrest.

Cardiac rehabilitation programs for high-risk individuals may include the following:

• 36 sessions (e.g., 3x/wk x 12 wks) of supervised exercise with continuous telemetry monitoring; and
• Educational program for risk factor/stress reduction; and
• Creation of an individual outpatient exercise program that can be self-monitored and maintained.

Note: If no clinically significant arrhythmia is documented during the first three weeks of the program, the remaining portion may be completed without telemetry monitoring.

Intermediate Risk:
Individuals in the intermediate risk category may have ANY of the following:

• Exercise test limited to 6-9 METS; or
• Ischemic ECG response to exercise of less than 2 mm of ST segment depression; or
• Uncomplicated myocardial infarction, coronary artery bypass surgery, or angioplasty and has a post-cardiac event maximal functional capacity of 8 METS or less on ECG exercise test.

Cardiac rehabilitation programs for intermediate risk individuals may include the following:

• Provide exercise training for 24 sessions or less of exercise training without continuous ECG monitoring (Note: Some individuals may require less than 3x/wk x 8 wks); and
• Be geared towards defining an ongoing exercise program that is self-administered.

Low Risk:
Individuals in the low risk category may have ANY of the following:

• Exercise test limited to greater than 9 METS; or
• Asymptomatic at rest.

Cardiac rehabilitation programs for low risk individuals may include the following:

• 6 one-hour sessions involving risk factor reduction education; and
• Supervised exercise to show safety and define a home program (for example 3x/week x 2wks or 2x/week x 3wks).

Finally, additional cardiac rehabilitation services may be warranted based on the above listed criteria and in the event the individual has any of the following indications:

• Another documented myocardial infarction or extension of initial infarction; or
• Another cardiovascular surgery or angioplasty; or
• New evidence of ischemia on an exercise test, including thallium scan; or
• New clinically significant coronary lesions documented by cardiac catheterization.

Cardiac Ejection Fraction (Ejection fraction or EF): The percentage of blood ejected from the left ventricle with each contraction, calculated as the ratio of stroke volume to end-diastolic volume. It serves as a key measure of left ventricular systolic function and is primarily affected by preload, afterload, and contractility. In the context of cardiac rehabilitation, ejection fraction is critical for patient classification, risk stratification, and treatment planning. The 2022 AHA/ACC/HFSA Heart Failure Guidelines define heart failure with reduced ejection fraction (HFrEF) as LVEF ≤40%, heart failure with mildly reduced ejection fraction (HFmrEF) as LVEF 41-49%, and heart failure with preserved ejection fraction (HFpEF) as LVEF ≥50%. Cardiac rehabilitation with supervised exercise training is recommended for individuals with stable heart failure and reduced ejection fraction, as well as for individuals after myocardial infarction or coronary revascularization. LVEF is typically measured using echocardiography, radionuclide angiography, or cardiac MRI, with accuracy varying by modality (±2-6% for radionuclide angiography, ±10% or more for echocardiography). In cardiac rehabilitation settings, LVEF is reassessed to monitor recovery, as improvement in LVEF occurs in a substantial proportion of affected individuals and is associated with better cardiovascular outcomes (Heidenreich, 2023).

Cardiac Rehabilitation: A physician-supervised, multidisciplinary secondary prevention program that includes physician-prescribed exercise, cardiac risk factor modification, psychosocial assessment, and outcomes assessment for people with cardiovascular disease. The program must have a physician medical director and be supervised by a physician or nonphysician practitioner with appropriate cardiovascular expertise who is immediately available for consultation or emergencies. According to the 2024 American Heart Association/American Association of Cardiovascular and Pulmonary Rehabilitation scientific statement, the core components of cardiac rehabilitation include individual assessment, nutritional counseling, weight management and body composition, cardiovascular disease and risk factor management (including blood pressure, lipids, diabetes, and tobacco cessation), psychosocial management, aerobic exercise training, strength training, physical activity counseling, and program quality monitoring. Each person undergoing cardiac rehabilitation must have an individualized treatment plan signed by a physician and updated at least every 30 days

Duke Treadmill Score (DTS): A validated risk stratification tool derived from exercise treadmill testing that incorporates exercise duration (typically measured in minutes on a standard protocol), ST-segment deviation, and exercise-induced angina. The angina index is scored as 0 (no angina), 1 (non-limiting angina), or 2 (exercise-limiting angina). Scores typically range from approximately −25 (highest risk) to +15 (lowest risk). DTS is commonly categorized as low risk (≥ +5), intermediate risk (−10 to +4), and high risk (≤ −11), and is used to estimate prognosis and guide management decisions.

Exercise Capacity: Exercise capacity in cardiac rehabilitation refers to the maximum amount of physical exertion that a person can sustain, reflecting the limitations of the cardiovascular system. This is distinct from functional capacity, which describes the ability to perform activities of daily living requiring sustained, submaximal aerobic metabolism. Exercise capacity is a critical outcome measure in cardiac rehabilitation programs and is typically assessed through objective testing methods. The gold standard for measurement is cardiopulmonary exercise testing (CPET), which quantifies peak oxygen uptake (VO₂ peak) and provides comprehensive insight into cardiovascular, respiratory, and muscular responses to exercise. When CPET is unavailable, alternative assessments include graded exercise testing with electrocardiography, the 6-minute walk test, or metabolic equivalent (MET) measurements (Del Buono, 2019).

Metabolic Equivalent (MET): The ratio of energy expenditure during physical activity to resting energy expenditure, with 1 MET defined as 3.5 mL O₂·kg⁻¹·min⁻¹, which is the average oxygen consumption during quiet sitting. In cardiac rehabilitation, METs are used to quantify exercise intensity, prescribe activity levels, and assess cardiorespiratory fitness (Strath, 2013).

New York Heart Association (NYHA) Classes of Heart Failure:

Peer Reviewed Publications:

1. Dunlay SM, Pack QR, Thomas RJ, et al. Participation in cardiac rehabilitation, readmissions, and death after acute myocardial infarction. Am J Med. 2014; 127(6):538-546.
2. García-Bravo S, Cano-de-la-Cuerda R, Domínguez-Paniagua J, et al. Effects of virtual reality on cardiac rehabilitation programs for ischemic heart disease: a randomized pilot clinical trial. Int J Environ Res Public Health. 2020; 17(22):8472.
3. Goel K, Lennon RJ, Tilbury RT, et al. Impact of cardiac rehabilitation on mortality and cardiovascular events after percutaneous coronary intervention in the community. Circulation. 2011; 123(21):2344-2352.
4. Gulick V, Graves D, Ames S, et al. Effect of a virtual reality-enhanced exercise and education intervention on patient engagement and learning in cardiac rehabilitation: Randomized Controlled Trial. J Med Internet Res. 2021; 23(4):e23882.
5. Johnson DA, Sacrinty MT, Gomadam PS, et al. Effect of early enrollment on outcomes in cardiac rehabilitation. Am J Cardiol. 2014; 114(12):1908-1911.
6. Kobashigawa JA, Leaf DA, Lee N, et al. A controlled trial of exercise rehabilitation after heart transplantation. N Engl J Med. 1999; 340(4):272-277.
7. Lee JY, Yun SC, Ahn JM, et al. Impact of cardiac rehabilitation on angiographic outcomes after drug-eluting stents in patients with de novo long coronary artery lesions. Am J Cardiol. 2014; 113(12):1977-1985.
8. Long L, Anderson L, He J, et al. Exercise-based cardiac rehabilitation for stable angina: systematic review and meta-analysis. Open Heart. 2019a; 6(1):e000989
9. O'Connor CM, Whellan DJ, Lee KL, et al. Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randomized controlled trial. JAMA. 2009; 301(14):1439-1350.
10. Pack QR, Dudycha KJ, Roschen KP, et al. Safety of early enrollment into outpatient cardiac rehabilitation after open heart surgery. Am J Cardiol. 2015; 115(4):548-552.
11. Reeves GR, Gupta S, Forman DE. Evolving role of exercise testing in contemporary cardiac rehabilitation. J Cardiopulm Rehabil Prev. 2016; 36(5):309-19.
12. Risom SS, Zwisler AD, Rasmussen TB, et al. Cardiac rehabilitation versus usual care for patients treated with catheter ablation for atrial fibrillation: Results of the randomized CopenHeartRFA trial. Am Heart J. 2016; 181:120-129.
13. Sibilitz KL, Berg SK, Rasmussen TB, et al. Cardiac rehabilitation increases physical capacity but not mental health after heart valve surgery: a randomised clinical trial. Heart. 2016; 102(24):1995-2003.
14. Sibilitz KL, Tang LH, Berg SK, et al. Long-term effects of cardiac rehabilitation after heart valve surgery - results from the randomised CopenHeartVR trial. Scand Cardiovasc J. 2022; 56(1):247-255.
15. Tarro Genta F, Tidu M, Bouslenko Z, et al. Cardiac rehabilitation after transcatheter aortic valve implantation compared to patients after valve replacement. J Cardiovasc Med (Hagerstown). 2017; 18(2):114-120.
16. Taylor RS, Brown A, Ebrahim S, et al. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med. 2004; 116(10):682-692.
17. Wilson JR, Groves J, Rayos G. Congestive heart failure/heart transplantation/pulmonary circulation: Circulatory status and response to cardiac rehabilitation in patients with heart failure. Circulation 1996; 94(7):1567-1572.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Association of Cardiovascular and Pulmonary Rehabilitation. Guidelines for Cardiac Rehabilitation Programs. Human Kinetics Publishers, 2020. [VitalSource Bookshelf].
2. Anderson L, Sharp GA, Norton RJ, et al. RS. Home-based versus centre-based cardiac rehabilitation. Cochrane Database Syst Rev. 2017;6:CD007130.
3. Anderson L, Taylor RS. Cardiac rehabilitation for people with heart disease: an overview of Cochrane systematic reviews. Cochrane Database Syst Rev. 2014;(12):CD011273.
4. Anderson L, Thompson D, Oldridge N, et al. Exercise-based cardiac rehabilitation for coronary artery disease. Cochrane Database Syst Rev. 2016;(67):CD001800.
5. Balady GJ, Williams MA, Ades PA, et al. Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation. 2007; 115(20):2675-2682.
6. Del Buono MG, Arena R, Borlaug BA, et al. Exercise Intolerance in Patients With Heart Failure: JACC State-of-the-Art Review. J Am Coll Cardiol. 2019; 73(17):2209-2225.
7. Dibben G, Faulkner J, Oldridge N, et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2021 Nov 6;11(11):CD001800.
8. Fletcher GF, Ades PA, Kligfield P, et al.; American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee of the Council on Clinical Cardiology, Council on Nutrition, Physical Activity and Metabolism, Council on Cardiovascular and Stroke Nursing, and Council on Epidemiology and Prevention. Exercise standards for testing and training: a scientific statement from the American Heart Association. Circulation. 2013; 128(8):873-934.
9. Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: a Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022; 145(18):e895-e1032.
10. King M, Bittner V, Josephson R, et al. AACVPR/AHA Scientific Statement medical director responsibilities for outpatient cardiac rehabilitation/secondary prevention programs: 2012 update a statement for health care professionals from the American Association of Cardiovascular and Pulmonary Rehabilitation and the American Heart Association. Circulation. 2012; 126(21): 2535-2543.
11. Lawton JS, Tamis-Holland JE, Bangalore S, et al. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022; 145(3):e18-e114
12. Leon AS, Franklin BA, Costa F, et al. Cardiac rehabilitation and secondary prevention of coronary heart disease: an American Heart Association scientific statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity), in collaboration with the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation. 2005; 111(3):369-376.
13. Long L, Mordi IR, Bridges C, et al. Exercise-based cardiac rehabilitation for adults with heart failure. Cochrane Database Syst Rev. 2024;3:CD003331.
14. Mosca L, Benjamin EJ, Berra K, et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women - 2011 update: a guideline from the American Heart Association. J Am Coll Cardiol, 2011; 57(12):1404-1423.
15. Pio CSA, Chaves G, Davies P, et al. Interventions to promote patient utilisation of cardiac rehabilitation. Cochrane Database Syst Rev. 2019;(2):CD007131.
16. Strath SJ, Kaminsky LA, Ainsworth BE, et al.; American Heart Association Physical Activity Committee of the Council on Lifestyle and Cardiometabolic Health and Cardiovascular, Exercise, Cardiac Rehabilitation and Prevention Committee of the Council on Clinical Cardiology, and Council. Guide to the assessment of physical activity: clinical and research applications: a scientific statement from the American Heart Association. Circulation. 2013; 128(20):2259-2279.
17. Thomas RJ, King M, Lui K, et al. AACVPR/ACCF/AHA 2010 update: performance measures on cardiac rehabilitation for referral to cardiac rehabilitation/secondary prevention services: a report of the American Association of Cardiovascular and Pulmonary Rehabilitation and the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Clinical Performance Measures for Cardiac Rehabilitation). J Cardiopulm Rehabil Prev. 2010; 30(5):279-288.
18. Thompson PD. Chapter 46: Comprehensive rehabilitation of patients with cardiovascular disease. In: Zipes DP, Libby P, Bonow RO, Braunwald E, editors. Braunwald’s heart disease. A textbook of cardiovascular disease. 8th ed. Philadelphia: Saunders. 2007.
19. Yamamoto S, Hotta K, Ota E, et al. Exercise-based cardiac rehabilitation for people with implantable ventricular assist devices. Cochrane Database Syst Rev. 2018; 9:CD012222.
20. Yancy CW, Drazner MH, Coffin ST, et al. 2020 ACC/HFSA/ISHLT lifelong learning statement for advanced heart failure and transplant cardiology specialists: a report of the ACC Competency Management Committee. J Am Coll Cardiol. 2020;75(10):1212-1230.

1. American Heart Association (AHA). What is cardiac rehabilitation? Last reviewed April 24, 2024. Available at: https://www.goredforwomen.org/en/health-topics/cardiac-rehab/what-is-cardiac-rehabilitation. Accessed on May 6, 2026.
2. New York Heart Association (NYHA) Classes of Heart Failure. Last reviewed May 21, 2025. Available at: https://www.heart.org/en/health-topics/heart-failure/what-is-heart-failure/classes-of-heart-failure. Accessed on  May 6, 2026.

Federal and State law, as well as contract language, and Medical Policy take precedence over Clinical UM Guidelines. We reserve the right to review and update Clinical UM Guidelines periodically. Clinical guidelines approved by the Medical Policy & Technology Assessment Committee are available for general adoption by plans or lines of business for consistent review of the medical necessity of services related to the clinical guideline when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card.

Alternatively, commercial or FEP plans or lines of business which determine there is not a need to adopt the guideline to review services generally across all providers delivering services to Plan’s or line of business’s members may instead use the clinical guideline for provider education and/or to review the medical necessity of services for any provider who has been notified that his/her/its claims will be reviewed for medical necessity due to billing practices or claims that are not consistent with other providers, in terms of frequency or in some other manner.

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