CG-REHAB-03 Pulmonary Rehabilitation

This document addresses the use of pulmonary rehabilitation for the treatment of various lung conditions. Pulmonary rehabilitation (PR) is an individually tailored multidisciplinary program of care for people with chronic respiratory impairment.

PR provided in the inpatient setting is considered not medically necessary when medical necessity criteria for PR are not met.

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.

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met.

According to the American Thoracic Society (ATS) pulmonary rehabilitation is defined as:

A comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies, which include, but are not limited to, exercise training, education, and behavior change, designed to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long-term adherence of health-enhancing behaviors.

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.

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; Dowman, 2021; Egan, 2012; Higashimoto, 2020; 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 (2012) conducted a pilot randomized controlled trial (RCT) with 30 subjects with non-cystic fibrosis bronchiectasis. 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 included 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.

An RCT by Lai and colleagues (2017) compared a preoperative, high-intensity, 7-day pulmonary rehabilitation program to standard care for 101 subjects preparing for lung cancer lobectomy. The primary endpoint was postoperative complications within 30 days of surgery, including atelectasis, acute respiratory distress syndrome, respiratory failure, mechanical ventilation, deep vein thrombosis/pulmonary embolism, and empyema/pneumonia. The researchers found that postoperative complications were significantly lower in the pulmonary rehabilitation group compared to the standard care group (5/51, 9.8% versus 14/50, 28%; p=0.019). In addition, the pulmonary rehabilitation group was able to walk further in 6 minutes (22.9 ± 25.9 m versus 4.2 ± 9.2 m), had better peak expiratory flow (increase of 25.2 ± 24.6 l/min versus 4.2 ± 7.7 l/min), and had a shorter postoperative hospital stay (6.1 ± 3.0 versus 8.7 ± 4.6 days; p=0.001). A total of 6 subjects did not complete the 7-day pulmonary rehabilitation program due to needing surgery early (2 cases), lack of endurance (2 cases), and perceived lack of benefit (2 cases). Overall, the researchers concluded that individuals with lung cancer benefit from a high-intensity, systematic, preoperative pulmonary rehabilitation program and have fewer postoperative complications.

In a joint consensus statement by the American Thoracic Society and the European Respiratory Society (2015), the following statement was made:

PR has demonstrated effectiveness for several respiratory conditions other than COPD. Randomized controlled trials demonstrating its beneficial effects on exercise capacity, symptoms, and/or health-related quality of life are available in interstitial lung disease, bronchiectasis, asthma, cystic fibrosis, lung transplantation, lung cancer, and pulmonary hypertension.

In a joint guideline published by the American College of Chest Physicians and the Canadian Thoracic Society (2016), the following recommendations were made for individuals with severe, or very severe COPD:

In a joint guideline by the American Thoracic Society and the European Respiratory Society (Wedzicha, 2017), the following statement was made:

Pulmonary rehabilitation implemented within 3 weeks after discharge following a COPD exacerbation reduces hospital admissions and improves quality of life, while pulmonary rehabilitation implemented within 8 weeks after discharge increases exercise capacity.

Multiple systematic reviews have been published that support the efficacy of PR in managing COPD-related illnesses (Gordon, 2019; Lee, 2016; Lee, 2019; Mantoani, 2016; Meshe, 2016; Paneroni, 2017; Yang, 2019; Yu, 2019) including a Cochrane Review which included 20 studies representing a total of 1477 individuals (Puhan, 2016).

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.

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

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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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Subject: Pulmonary Rehabilitation
Guideline #: CG-REHAB-03	Publish Date: 07/06/2022
Status: Reviewed	Last Review Date: 05/12/2022

CPT
94625	Physician or other qualified health care professional services for outpatient pulmonary rehabilitation; without continuous oximetry monitoring (per session)
94626	Physician or other qualified health care professional services for outpatient pulmonary rehabilitation; with continuous oximetry monitoring (per session)

HCPCS
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	Pre-operative 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
S9473	Pulmonary rehabilitation program, non-physician provider, per diem

ICD-10 Diagnosis
	All diagnoses

Status	Date	Action
Reviewed	05/12/2022	Medical Policy & Technology Assessment (MPTAC) review. Updated References section.
	12/29/2021	Updated Coding section with 01/01/2022 CPT and HCPCS changes; added 94625, 94626 effective 01/01/2022, removed G0424 deleted 12/31/2021.
Reviewed	05/13/2021	MPTAC review. Discussion/General Information and References sections updated. Reformatted Coding section.
Reviewed	05/14/2020	MPTAC review. References section updated.
Reviewed	06/06/2019	MPTAC review. References section updated.
Reviewed	07/26/2018	MPTAC review. The document header wording updated from “Current Effective Date” to “Publish Date.” Discussion/General Information and References sections updated.
Reviewed	08/03/2017	MPTAC review. Updated Discussion/General Information and References section.
Reviewed	08/04/2016	MPTAC review. Updated Reference section. Removed ICD-9 codes from Coding section.
Revised	08/06/2015	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.
Reviewed	08/18/2011	MPTAC review.
Reviewed	08/19/2010	MPTAC review.
	01/01/2010	Updated coding section with 01/01/2010 HCPCS changes.
Reviewed	08/27/2009	MPTAC review.
Reviewed	08/28/2008	MPTAC review.
	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
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)