Clinical UM Guideline

This document addresses the use of ambulatory (outpatient) 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.

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

Medically Necessary:

Pulmonary rehabilitation (PR) is considered medically necessary in individuals who meet the following criteria:

1. Individual is preparing for or recovering from surgical interventions such as:
   1. Lung transplantation; or
   2. Lung volume reduction surgery; or
   3. Post-operative states; (for example, thoracic or abdominal surgery).
      or
2. Individual has any of the following conditions:
   1. Chronic obstructive pulmonary disease such as:
      1. Asthma; or
      2. Bronchiectasis; or
      3. Chronic bronchitis; or
      4. Cystic fibrosis; or
      5. Emphysema;
         or
   2. Restrictive diseases such as:
      1. Chest wall disease; or
      2. Interstitial disease; or
      3. Post-polio syndrome; or
      4. Selected neuromuscular disorders; or
      5. Thoracic cage abnormalities;
         or
   3. Stable lung cancer; or
   4. Individual with pre-existing or ongoing lung function impairment associated with prior COVID-19;
      and
3. Individual continues to have disabling dyspnea despite optimal medical management associated with the following:
   1. A restriction in ordinary activities: and
   2. Significant impairment in quality of life;
      and
4. Individual is motivated to participate in a PR program; and
5.  Individual is free from the following (1 and 2 below):
   1. Conditions that may interfere with the individual undergoing the rehabilitative process, including but not limited to:
      1. Advanced symptomatic arthritis; or
      2. Disruptive behavior; or
      3. Inability to learn;
         and
   2. Conditions that may place the individual at undue risk during exercise training, including but not limited to:
      1. Recent myocardial infarction; or
      2. Severe pulmonary hypertension; or
      3. Unstable angina.

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 is considered not medically necessary when criteria above are not met.

This document describes clinical studies and expert recommendations, and explains whether pulmonary rehabilitation services are 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

Pulmonary rehabilitation (PR) is a structured treatment program for people with long-term lung disease. It combines exercise training, education, breathing techniques, and support to help people breathe better, improve strength and stamina, and feel more independent. PR may take place in a center or at home using remote support. Studies show that PR can improve shortness of breath, walking ability, and quality of life for people with conditions that impact the ability to breathe such as chronic obstructive pulmonary disease (COPD), interstitial lung disease (ILD), lung cancer, pulmonary hypertension, and ongoing breathing problems after COVID-19. Like any exercise program, PR may not be safe for people with certain serious health problems.

What the Studies Show

PR programs usually include supervised exercise, breathing exercises, and education about lung disease. Many high-quality studies show that PR improves distance a person can comfortably walk, reduces shortness of breath, and improves quality of life in adults with COPD and ILD. Research also shows that starting PR soon after a hospital stay for COPD lowers the risk of having to go back to the hospital and improves quality of life. For people with lung cancer, one study found that a short PR program before surgery lowered the risk of problems after surgery and shortened hospital stays. For pulmonary hypertension, studies show improved exercise ability and quality of life, with no clear increase in serious side effects, although the certainty of the evidence is low in some areas.

For people recovering from COVID-19, several studies show that PR or similar exercise-based programs can improve walking distance, muscle strength, fatigue, and short-term quality of life. Some studies were small or had limits in design and better studies are needed to know how long these benefits last. The possible harm from PR in these studies indicated they were uncommon, and serious side effects were rare.

When is Pulmonary Rehabilitation Clinically Appropriate?

Pulmonary rehabilitation may be appropriate in these situations:

• A person is preparing for or recovering from lung transplantation, lung volume reduction surgery, thoracic surgery, or abdominal surgery; or
• A person has one of the following lung conditions: COPD, including asthma, bronchiectasis, chronic bronchitis, cystic fibrosis (CF), or emphysema; or restrictive lung diseases, such as chest wall disease, interstitial lung disease (ILD), post-polio syndrome, selected neuromuscular disorders, or thoracic cage abnormalities; or stable lung cancer; or ongoing lung function problems after prior COVID-19;
  and
  • The person continues to have disabling shortness of breath despite best medical treatment; and
  • Has limits in daily activities; and
  • Has a reduced quality of life; and
  • The person is motivated to take part in the program; and
  • The person does not have conditions that would interfere with rehabilitation, such as advanced symptomatic arthritis, disruptive behavior, or inability to learn; and
  • The person does not have conditions that would make exercise unsafe, such as a recent heart attack, severe pulmonary hypertension, or unstable angina.

Repeat PR may be appropriate for people who need a second program related to lung transplantation or lung volume reduction surgery, if the above criteria are met.

When is this not Clinically Appropriate?

Pulmonary rehabilitation is not clinically appropriate when the criteria listed above are not met, including scenarios other than those listed above.

(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.

Summary:

Pulmonary rehabilitation (PR) is strongly supported by major respiratory societies as an effective intervention for a wide range of chronic respiratory conditions, particularly chronic obstructive pulmonary disease (COPD), where it improves exercise capacity, symptoms, quality of life, and reduces hospitalizations, especially when initiated soon after exacerbation. Guidelines also recommend PR for interstitial lung disease (ILD) and support its use in other conditions such as bronchiectasis, asthma, pulmonary hypertension, lung cancer, and post-lung transplant, with emerging evidence for benefits in COVID-19 recovery. Clinical studies and meta-analyses consistently demonstrate that PR enhances functional capacity, reduces dyspnea, and improves health-related quality of life across these populations. Additional evidence suggests PR may reduce healthcare utilization and postoperative complications in lung cancer, and improve outcomes in pulmonary hypertension and ILD, though evidence quality varies for some conditions. Overall, PR is a key, evidence-based component of comprehensive respiratory care, with benefits influenced by timely initiation, program structure, and ongoing adherence to maintenance strategies.

Discussion:

Several specialty societies provide recommendations for PR programs for a number of respiratory conditions.

The ATS/European Respiratory Society (ERS) Joint Statement (2015) states:

PR has demonstrated effectiveness for several respiratory conditions other than COPD. Randomized controlled trials demonstrate improvements in exercise capacity, symptoms, and/or health-related quality of life in the following conditions: COPD, ILD, bronchiectasis, asthma, CF, lung transplantation, lung cancer, and pulmonary hypertension.

The joint 2016 American College of Chest Physicians (ACCP)/Canadian Thoracic Society (CTS) Guideline recommends PR for individuals with severe or very severe COPD following a COPD exacerbation as follows:

Recent exacerbation (≤ 4 weeks): PR is recommended to prevent acute exacerbations of COPD (Grade 1C).
Exacerbation > 4 weeks prior: PR is not suggested specifically for the purpose of preventing acute exacerbations (Grade 2B).

The joint American Thoracic Society (ATS)/ERS Guideline on COPD Exacerbations supports timely implementation of PR after COPD hospitalization to improve clinical outcomes (Wedzicha, 2017). The recommendation states:

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.

The ERS/ATS Coordinated International Task Force (COVID-19 Rehabilitation) (Spruit, 2020) issued interim guidance on COVID-19 rehabilitation in the hospital and post-hospital phase which states:

Individuals with pre-existing or ongoing lung function impairment at 6-8 weeks following hospital discharge receive a comprehensive PR program consistent with established international standards, compared to no PR program.

Although standard post-exacerbation PR is typically initiated within 4 weeks of hospital discharge, the ERS/ATS COVID-19 Task Force recommended delaying initiation to 6-8 weeks post-discharge for COVID-19 survivors. This modification was based on uncertainty regarding duration of post-infectious viral risk, evidence suggesting that at 2 months a proportion of physical recovery will have occurred, and practical challenges associated with enrolling individuals into rehabilitation programs at 4 weeks following discharge.

The 2023 updated ATS Clinical Practice Guideline: Pulmonary Rehabilitation for Adults with Chronic Respiratory Disease issued the following recommendations:

Strong Recommendations (Moderate-Quality Evidence):

• Adults with stable COPD should participate in PR.
• Adults with COPD following hospitalization for exacerbation should participate in PR.
• Adults with ILD should participate in PR.
• Adults with stable chronic respiratory disease should be offered a choice of center-based PR or telerehabilitation.

Conditional Recommendations:

• Adults with pulmonary hypertension may participate in PR (low-quality evidence).
• Adults with COPD may participate in supervised maintenance PR following completion of an initial PR program (low-quality evidence).

Additionally, the National Comprehensive Cancer Network (NCCN^®) Non-Small Cell Lung Cancer Survivorship Guidelines (V3.2026) recommends consideration of perioperative PR for individuals with comorbid COPD and for those undergoing lung surgery. In palliative care settings, NCCN supports referral to PR for individuals with COPD or pulmonary hypertension when appropriate as part of optimization of comorbid conditions.

Overall the guidance across specialty societies demonstrates that PR is strongly recommended for individuals with stable COPD and following COPD hospitalization for exacerbation, early initiation provides the greatest benefit in reducing readmissions and improving quality of life. PR is also recommended for individuals with ILD, and may be considered for pulmonary hypertension, lung cancer, and other chronic respiratory diseases based on available evidence. COVID-19 survivors with persistent pulmonary impairment may also benefit from comprehensive PR.

Peer Reviewed Literature:

Several studies have demonstrated important benefits of PR including reducing dyspnea (shortness of breath) and improving exercise capacity, total energy expenditure, and 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 (2005) demonstrated a non-significant trend for PR to increase 5-year survival. Mandal (2012) conducted a pilot randomized controlled trial (RCT) with 30 participants with non-cystic fibrosis bronchiectasis. The primary outcome measure was the incremental shuttle walking test (ISWT). Study authors reported no benefit for participants in the control group, who received chest physiotherapy only, at the end of 8 weeks of therapy, or at 20 weeks post-therapy. Participants 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 improved significantly 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.

COPD:

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 common for the person to receive therapy 3 times per week for 4 to 6 weeks.

Lim (2025) conducted a review of five studies (n=1544) evaluating barriers and enablers to center-based PR among individuals with COPD in low- and middle-income countries (Iran, China, Colombia, Brazil). The most frequently reported barrier was personal financial constraints. Additional barriers included COPD symptom severity, limited family/social support, insufficient healthcare professional competency, and logistical challenges. Identified enablers included greater healthcare professional competency proficiency, higher personal and family income, higher educational attainment, and increased awareness of PR through educational initiatives. Barriers and facilitators occurred at multiple levels (intrapersonal, interpersonal, organizational, community, and policy). While several factors including hospitalization frequency, social support, healthcare professional competency knowledge, logistics and awareness were consistent with high-income country findings, financial constraints were uniquely prominent in low- and middle-income settings. The authors concluded that these multilevel determinants should be considered in PR program development, implementation, and access planning.

COVID-19:

Li (2021) reported the results of a parallel-group, RCT, with 1:1 block randomization of 120 previously hospitalized COVID-19 survivors with complaints of lingering dyspnea. The study investigated whether survivors in a 6-week telerehabilitation program (n=59) via smartphone, and remotely monitored with heart rate telemetry, could improve functional exercise capacity, pulmonary function, lower limb muscle strength, health related quality of life (HR-QOL), and dyspnea versus no rehabilitation (control n=61). The study demonstrated that 6-minute walking distance in the control group increased by 17.1 m from baseline at 6-week post-treatment assessment, whereas 6-minute walking distance in the treatment group improved by 80.2 m. The adjusted between-group difference in change from baseline was 65.45 m (p<0.001). Additionally, lower muscle strength was measured via static squat test in how many seconds participants could remain in the squatting position. This measurement also improved to a greater degree in the treatment group as compared with the control group. Squat test times were 20.12s post-treatment (p<0.001), and 22.23s (p<0.001) at 24-week follow-up. Lung function also improved in both groups. However, no differences were found between groups apart from a change from baseline of 10.57 l/min (p=0.005) in post-treatment maximum voluntary ventilation (MVV) in the treatment group. HR-QOL as measured by the Short Form Health Survey-12 and Modified Medical Council Dyspnea Scale, also increased to a greater degree in the treatment group at post-treatment 3.79 points (p=0.004) and 2.69 points at follow-up (p=0.045), with 90.4% being dyspnea-free in the treatment group as opposed to 61.7% in the control group (p=0.001). Interestingly, a treatment effect on dyspnea was found immediately after the treatment but not at follow up. No serious adverse events occurred during the study. Eight individuals (5 in the treatment and 3 in the control group) were hospitalized, all for non-life-threatening reasons unrelated to COVID-19 or the intervention, and all in the follow-up period. The authors concluded that the telerehabilitation program was superior over no intervention with regard to functional exercise capacity, lower muscle strength, and physical HR-QOL. Short term effects were found for self-reported dyspnea and MVV. The effects of the program on pulmonary function are otherwise unlikely and effects on the mental aspects of QOL are small at best.

Hockele (2022) also reported the results of a clinical trial which studied the effects of pulmonary and physical rehabilitation on functional capacity via 6-minute walk test, pulmonary function measured by spirometry, respiratory muscle strength by manovacuometry, handgrip strength by dynamometry, QOL by the COPD Assessment Test, and functional status by the Post Covid Functional Status Test. Twenty-nine (n=29) individuals diagnosed with post-COVID-19 mild, moderate, or severe involvement by chest tomography, underwent 16 sessions in a rehabilitation program. After testing participants performed inspiratory muscle training exercises (IMT), aerobic exercise and peripheral muscle strength exercises, standardized by a protocol 2 times per week, for 60 min each. After 2 months of treatment, participants were reassessed to measure their individual improvements. The functional capacity increased in meters walked from 326.3 ± 140.6 to 445.4 ± 151.1 (p<0.001), with an increase in the predicted value from 59.7% to 82.6% (p<0.001). The lung function increased in liters from 2.9 ± 0.8 to 3.2 ± 0.8 (p=0.004) for forced vital capacity and from 2.5 ± 0.7 to 2.7 ± 0.7 (p=0.001) for forced expiratory volume in the first second. The respiratory muscle strength increased in cmH2O from 101.4 ± 46.3 to 115.8 ± 38.3 (p=0.117) for inspiratory pressure and from 85.8 ± 32.8 to 106.7 ± 36.8 (p<0.001) for expiratory pressure. The authors concluded that the program provided an improvement in all domains for the participants, restoring their QOL.

A parallel, 2-arm, double-blinded, RCT by del Corral (2024) examined the impact of adding respiratory muscle training (RMT) to an 8-week aerobic exercise (AE) program in 64 individuals with long-term post-COVID fatigue and dyspnea. The program included AE 50 min/day 2 times/week; RMT: 40 min/day 3 times/week. The participants were randomised to 1 of 2 parallel groups, AE+RMT (n=32) and AE+RMT sham group (n=32). Pre-intervention characteristics did not differ significantly between the groups. The primary outcomes measured were HR-QOL and exercise tolerance based on cardiopulmonary exercise test. Secondary outcomes were respiratory muscle function (inspiratory-expiratory muscle strength and inspiratory muscle endurance), lower and upper limb strength (1-min Sit-to-Stand and handgrip force); lung function: (spirometry testing and lung diffusing capacity); and psychological status (anxiety/depressive levels). Both groups showed improvements for exercise tolerance (AE+RMT, p<0.001; control, p<0.001), as well as HR-QOL (AE+RMT, p<0.001; control, p<0.001). The AE+RMT group showed statistically significant improvements in respiratory muscle strength and inspiratory muscle endurance compared to the control group; maximal static inspiratory pressure =p<0.001, maximal static expiratory pressure =p<0.00, inspiratory muscle endurance p=0.004. There were no statistically significant intergroup differences in upper and lower limb peripheral muscle strength assessed by the 1-min STS and handgrip. Lung function showed a statistically significant intergroup difference in peak expiratory flow (PEF); the AE+RMT group obtained a low-moderate increase in PEF compared with the control group (p=0.044). In addition, only the AE+RMT group had a statistically significant, albeit slight, increase in diffusion capacity after the intervention compared with baseline lung diffusion capacity (p=0.035). The authors concluded that combining RMT with AE benefits respiratory muscles more than AE alone, though health and functional outcomes were similar between groups. The study is limited by its small sample size, lack of blinding, and other factors. Future studies with more robust methodology are needed to corroborate findings.

Ortiz-Ortigosa (2024) reported a systematic review and meta-analysis to study the effectiveness of PR programs and/or respiratory muscle training on respiratory sequelae in individuals with long term post-COVID. Five RCTs were included in the analysis. Study inclusion criteria were: participants aged 18 years or older, studies included at least one therapy involving PR or respiratory muscle training, participants were currently COVID negative, and if interventions were conducted with supervision or at home. The outcomes measured were the 6-minute walk test, dyspnea, fatigue, pulmonary function, maximum inspiratory pressure, and QOL. In one study, exercise capacity increased in both groups, but there was a greater improvement in the intervention group compared to the control group (p=0.001). In another study, exercise capacity improved in both the group that underwent PR through remote treatment and the group that followed the conventional program; no significant differences was observed between the two groups. In another study, improvement was also identified in both groups after treatment (p>0.001). Regarding lung function, the first study assessed lung function but did not demonstrate statistically significant improvement following the rehabilitation program. Another showed improvement in the intervention group only. The last study did not identify significant changes in terms of VO2 max (p>0.05), however, significant individual improvements were observed in two of the groups; the CT (multicomponent exercise program) and CTRM (multicomponent exercise program plus IMT program) (p<0.05). Only one of the studies assessed maximum static inspiratory pressure, showing improvement in the intervention group (p<0.001). Regarding dyspnea, two studies demonstrated a reduction in dyspnea in both control and intervention groups, the group that used diaphragm release plus IMT showed greater improvement compared to the group that only underwent IMT as a treatment. The second study showed dyspnea improvement in both the control group (p<0.004) and in the intervention group (p<0.03), which was not statistically significant. Another study showed that the control group only demonstrated partial improvement in dyspnea (p=0.02). Regarding fatigue, one study showed reduction in the intervention group (p<0.001) and in the control group (p=0.001), there was a statistically significant difference between the two groups in favor of the intervention group. In another study, both groups showed a statistically significant difference after the intervention (p<0.001). However, another study identified a significant improvement in the intervention group only. In the last study, fatigue significantly improved in the CT and CTRM groups (p<0.05). Two studies assessed the QOL, one of them identified improvement in the intervention group (p=0.003), the other study did not demonstrate a statistically significant improvement in either of the groups. The authors concluded that despite the absence of a specific treatment, their review demonstrated that a well-structured PR program that incorporates both aerobic and muscular strength exercises along with techniques and inspiratory muscle exercises was the most effective form of treatment.

Daynes (2025) conducted a single-blind randomized controlled trial (n=181) evaluating 8-week face-to-face exercise-based rehabilitation, remote individualized exercise and education, and usual care in adults with post-COVID syndrome following hospitalization. Participants were 55% male, mean age 59 ± 12 years, with a mean hospital stay of 12 ± 19 days. The primary outcome was change in Incremental Shuttle Walk Test (ISWT) distance at 8 weeks. Compared with usual care, ISWT distance improved significantly with face-to-face rehabilitation (mean +52 m; 95% confidence interval [CI], 19-85; p=0.002) and remote rehabilitation (mean +34 m; 95% CI, 1-66; p=0.047). No significant between-group differences were observed in self-reported health-related quality of life (HRQoL), although improvements were noted in the usual-care group, particularly in EuroQol 5-Dimension index (EQ-5D) a standardized, preference-based measure of HRQoL which includes anxiety and depression. An exploratory immunologic sub-study (n=31) evaluated lymphocyte subsets. Post-COVID syndrome is associated with immune dysregulation, including reductions in naïve T-cell populations and altered memory and senescent T-cell profiles. Exercise-based rehabilitation was associated with increases in naïve and memory CD8+ T-cell subsets compared with usual care (p<0.001), suggesting potential partial restoration of antiviral immune function. No evidence of adverse immunologic effects was observed. The findings are exploratory due to small sample size. Trial limitations include inclusion of only previously hospitalized individuals, participant allocation influenced by intervention access, this led to some differences between groups with those unable to attend remote programs being older, and limited sample size for immune analyses. Overall, exercise-based rehabilitation improved short-term exercise capacity in adults with post-COVID syndrome following hospitalization and demonstrated potential immunomodulatory effects, without evidence of harm in the studied population.

Volckaerts (2025) reported the PuRe-COVID trial, a pragmatic RCT evaluating the effect of a 12-week, stepwise PR program delivered in primary care for individuals with long COVID. A total of 76 participants (PR n=39; control n=37; mean age 49 ± 13 years) were randomized to either structured PR or no rehabilitation. The primary endpoint was change in 6-minute walk distance (6MWD) at 12 weeks, with additional outcomes including fatigue, dyspnea, inspiratory and expiratory muscle strength, hand grip strength, physical activity, and HRQoL, assessed through 36 weeks. At 12 weeks, participants receiving PR demonstrated a statistically significant improvement in 6MWD compared with controls (+39 meters; 95% CI, 18-59; p<0.001). The intervention group was also more likely to achieve clinically meaningful improvements in exercise capacity, fatigue (Checklist Individual Strength-fatigue score), inspiratory muscle strength (maximal inspiratory pressure), and dyspnea (modified Medical Research Council scale). Although no significant between-group differences were observed in HRQoL, high baseline EQ-5D-5L index scores in the intervention group may have limited the ability to detect change. The trial was terminated prior to reaching its planned sample size due to declining COVID-19 infection rates, reduced confirmatory testing, and budgetary constraints. The modest sample size limits precision and generalizability. The authors concluded that primary care-based PR was associated with statistically significant improvements in functional exercise capacity, fatigue, inspiratory muscle strength, and dyspnea in individuals with long COVID. Although findings should be interpreted cautiously due to early termination and sample size limitations, however, they may offer valuable insights, with the limitations unlikely to significantly compromise the validity or applicability of the conclusions.

Lung Cancer:

An RCT by Lai (2017) compared a preoperative, high-intensity, 7-day PR program to standard care for 101 participants 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 PR group compared to the standard care group (5/51, 9.8% versus 14/50, 28%; p=0.019). In addition, the PR group was able to walk further in 6 minutes (22.9 ± 25.9 m vs. 4.2 ± 9.2 m), had better peak expiratory flow (increase of 25.2 ± 24.6 l/min vs. 4.2 ± 7.7 l/min), and had a shorter postoperative hospital stay (6.1 ± 3.0 vs. 8.7 ± 4.6 days; p=0.001). A total of 6 participants did not complete the 7-day PR 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 PR program and have fewer postoperative complications.

Pulmonary Hypertension:

A Cochrane meta-analyses (Morris, 2023) evaluated the benefits and harms of exercise-based rehabilitation for individuals with pulmonary hypertension (PH) compared with usual care or no exercise-based rehabilitation (control group). The review included 11 RCTs with 462 participants, study durations ranged from 3-25 weeks. The primary outcomes measured were; exercise capacity, serious adverse events during the intervention period, and HR-QOL scores. Secondary outcomes measured were cardiopulmonary hemodynamics, functional class, clinical worsening during follow-up, and mortality. Exercise-based programs included inpatient and outpatient-based programs. The mean six-minute walk distance following exercise-based rehabilitation was 48.52 meters higher in the exercise based group than in the control group (72%, 11 studies, 418 participants), the mean peak oxygen uptake was 2.07 mL/kg/min higher in the exercised based group than in the control group (67%; 7 studies, 314 participants), and the mean peak power was 9.69 watts higher than in the exercise group than in the control group (71%; 5 studies, 226 participants). Three studies reported 5 serious adverse events, however, exercise-based rehabilitation was not associated with an increased risk of serious adverse events (risk difference 0, 95% CI). The mean change in HR-QOL SF-36 Physical Component Score was 3.98 points higher and for the SF-36 Mental Component Score was 3.60 points higher. Two studies reported mean reduction in mean pulmonary arterial pressure following exercise-based rehabilitation (mean reduction: 9.29 mmHg) 2 studies, 133 participants. The authors concluded that exercise-based rehabilitation may result in an increase in exercise capacity, however the changes were heterogeneous and could not be explained by subgroup analysis. Exercise training may also result in a reduction in mean pulmonary arterial pressure. The certainty of the evidence was assessed to be low for exercise capacity and mean pulmonary arterial pressure, and moderate for HR-QOL and adverse events. Future RCTs are needed to further assess the use and safety of exercise-based rehabilitation in individuals with PH, including those with chronic thromboembolic PH, PH with left-sided heart disease and those with more severe disease.

Restrictive Lung Disease:

Chen (2025) conducted a meta-analysis of 33 studies of individuals (n=1671) with ILD to evaluate the clinical benefits of PR. The pooled analysis demonstrated that PR significantly improved exercise endurance, reduced exertional hypoxemia, decreased dyspnea, and enhanced health-related quality of life (all p<0.05). Specifically, improvements were observed in 6-minute walk distance (6MWD), lowest oxygen saturation during the 6-minute walk test, Borg dyspnea scores, and SF-36 quality-of-life scores. Subgroup analyses indicated that PR programs of 4-8 weeks’ duration were associated with optimal benefit. Programs incorporating breathing training were more effective in improving exercise endurance. Center-based, home-based, and tele-rehabilitation delivery models all demonstrated benefit, with no significant differences observed between modalities. The analysis was limited by heterogeneity among included studies, including lack of classification by ILD etiology or pathology, absence of stratification by disease severity or lung function stage, and potential variability in minimal clinically important differences due to pooled subgroup analyses. Overall, the evidence supports PR as an effective therapeutic intervention for individuals with ILD, demonstrating meaningful improvements in functional exercise capacity and quality of life. However, further large-scale, well-designed studies are needed to define optimal program characteristics and clarify effectiveness across specific ILD subtypes and stages of disease.

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 PR programs result in additive long-term benefits in terms of dyspnea, exercise tolerance, or HR-QOL measures.

COVID-19 (Coronavirus Disease 2019): A communicable respiratory illness caused by infection with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). According to the Centers for Disease Control and Prevention (CDC), a confirmed case for public health surveillance purposes is defined by laboratory evidence of SARS-CoV-2 infection using a nucleic acid amplification test (NAAT) or other confirmatory diagnostic testing. Surveillance case definitions are intended for public health reporting and are not designed to replace clinical judgment in diagnosis or management (CDC, 2020).

Long COVID (Post-COVID Conditions): A serious condition characterized by new, returning, or ongoing symptoms and/or chronic health conditions that persist for weeks, months, or longer following infection with SARS-CoV-2, the virus that causes COVID-19. Long COVID may result in functional impairment and disability and can occur in individuals of any age, including children, regardless of the severity of the initial infection (CDC, 2025).

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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 February 25, 2026.
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4. Center for Disease Control and Prevention. Health Topics: Chronic obstructive pulmonary disease (COPD). May 15, 2024. Available at: https://www.cdc.gov/copd/about/?CDC_AAref_Val=https://www.cdc.gov/copd/features/copd-symptoms-diagnosis-treatment.html. Accessed on February 25, 2026.
5. Centers for Medicare and Medicaid Services. National Coverage Determination. Available at https://www.cms.gov/medicare-coverage-database/new-search/search.aspx. Accessed February 19, 2025.
   • Pulmonary Rehabilitation. NCD #240.8. Effective September 25, 2007.
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Asthma
Bronchiectasis
Chronic Bronchitis
Chronic Obstructive Pulmonary Disease
Chronic Respiratory Impairment
COVID-19
Cystic Fibrosis
Emphysema
Long COVID
Lung Transplantation
Lung Volume Reduction
Post-Polio Syndrome
Pulmonary Rehabilitation

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