CurrentAetnaPolicy 0032

Pulmonary Rehabilitation

Defines medical necessity, limitations, exclusions, coding, and documentation requirements for outpatient pulmonary rehabilitation programs, including candidates (disease states), functional thresholds, contraindications, duration expectations, and related billing codes.

Policy Summary

PayerAetna

PolicyPulmonary Rehabilitation

Policy CodePolicy 0032

Change Typeclarified

Effective Date

Next Review DateJan 11, 2024

Key ActionMaintain comprehensive initial evaluation and periodic re-evaluations with documented treatment descriptions, periodic objective exercise testing, team conference notes, justification for continuing therapy, and communication with the referring physician.

SourceLink

POLICY UPDATE CHANGES

Policy history shows last review on 03/15/2023 and next review scheduled for 01/11/2024.

36Program duration (hours)

6Typical duration (weeks)

≤20VO2max threshold

<60%PFT threshold

MultipleCovered indications discussed

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Coverage Summary

Scope: This policy addresses outpatient Pulmonary Rehabilitation and defines the medical necessity, limitations, exclusions, coding and documentation requirements for supervised pulmonary rehabilitation programs.

Coverage stance: Pulmonary rehabilitation is covered with criteria when all medical necessity requirements are met (listed chronic pulmonary conditions, dyspnea, reduced exercise tolerance, symptoms despite medical management, functional thresholds, ability/motivation, and absence of contraindicating conditions).

Typical program expectations: A typical supervised course is up to 6 weeks or 36 hours of therapy, with initial and periodic reassessments and documentation; continuation beyond the typical course requires demonstration of progress and expectation of further improvement.

Key thresholds & quick facts

VO2max threshold≤ 20 ml/kg/min (about 5 METS)

PFT percent predicted thresholdFEV1, FVC, FEV1/FVC, or Dlco < 60% predicted

Typical program durationUp to 6 weeks or 36 hours of therapy

Smoking cessation recommendationQuit smoking ≥ 3 months prior to program (appropriate candidates)

Covered indications discussedMultiple conditions (COPD, ILD, bronchiectasis, sarcoidosis, lung cancer, long COVID/post-exacerbation settings)

Medical-Necessity Criteria

Coding

Covered CPT codes if selection criteria are metCPTCovered

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)

Other related CPT rangesCPT

78580-78599	Diagnostic radiology, respiratory system (examples)
94010-94624	Pulmonary laboratory medicine (range)
94627-94799	Pulmonary laboratory medicine (range)

Covered HCPCS codes if selection criteria are metHCPCSCovered

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, 2 or more individuals (includes monitoring)
S9473	Pulmonary rehabilitation program, non-physician provider, per diem

HCPCS related (exercise equipment) - typically excluded by plansHCPCSNot Covered

A9300

Exercise equipment

ICD-10 codes covered if selection criteria are metICD-10Covered

C34.00-C34.92	Malignant neoplasm of bronchus and lung [Lung cancer]
D86.0-D86.9	Sarcoidosis
E84.0-E84.9	Cystic fibrosis
E88.01	Alpha-1-antitrypsin deficiency
G65.0-G65.2	Sequelae of inflammatory and toxic polyneuropathies
G70.00-G70.9	Myasthenia gravis and other myoneural disorders
G71.00-G71.9	Primary disorders of muscles
G72.0-G72.9	Other and unspecified myopathies
J40-J47.9	Chronic lower respiratory diseases
J60-J70.9	Lung diseases due to external agents

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ICD-10 codes contraindicated for this CPBICD-10Not Covered

C00.0-C33, C37-C96.9	Malignant neoplasm [not covered for pre-operative pulmonary rehabilitation, except lung cancer]
F17.200-F17.299	Nicotine dependence [recent or has quit for less than 3 months]
I21.01-I22.9	ST elevation and non-ST elevation myocardial infarction [within last 6 months]
I21.A1	Myocardial infarction type 2
I21.A9	Other myocardial infarction type
I25.10-I25.9	Chronic ischemic heart disease [symptomatic]
I47.0-I49.9	Paroxysmal tachycardia, atrial fibrillation and flutter and other cardiac arrhythmias
I50.20-I50.9	Heart failure
I73.89-I73.9	Other specified and unspecified peripheral vascular disease [claudication]
I82.0-I82.91	Other venous embolism and thrombosis [claudication]

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Provider Actions & Billing Impact

Documentation Required

Document initial assessment and periodic reassessments

Maintain a comprehensive initial evaluation and periodic re-evaluations (about every 2-4 weeks) including dated treatment descriptions for each visit, periodic exercise testing (usually at least every 5 visits) demonstrating improvement, periodic reassessment of goals/treatment plan, team conference notes (usually bi-weekly), treatment plan justification for continuing therapy, and evidence of communication with referring physician.

Comprehensive initial evaluation
Periodic re-evaluations (about every 2–4 weeks)
Periodic exercise testing (usually at least every 5 visits) showing improvement
Periodic reassessment of goals and treatment plan
Team conference notes (usually bi-weekly)
Treatment plan with justification for continuing therapy
Evidence of communication with referring physician

Background & Evidence

Goals: Pulmonary rehabilitation aims to stabilize or reverse impairments, restore maximal functional capacity and independence, improve day-to-day functioning and coping, and enable transfer of care to a home self-management regimen.

Components: Programs are multi-disciplinary and individualized and may include assessment, education, breathing exercises, respiratory muscle training, graded aerobic and strength exercise, nutritional interventions, psychosocial support, and lifestyle modification conducted in an outpatient setting.

Candidate selection: Ideal candidates are those with moderate to moderately severe disease, stable on standard medical therapy, motivated, physically able to participate, and without serious unstable comorbidities that would undermine benefit.

Individualization and transition: Every program should be individualized with a comprehensive initial evaluation, explicit goals, a documented treatment plan with frequencies and anticipated duration, periodic re-evaluations (about every 2–4 weeks) and the explicit objective of transitioning the patient to a home-based self-care exercise regimen once skills are acquired.

Utility by severity: The policy emphasizes PR is most useful for patients with COPD and is generally most beneficial for those with moderate to moderately severe disease; persons with very severe pulmonary impairment are not appropriate candidates.

Study / Guideline	Key finding
Cochrane review (Puhan et al 2009)	PR reduced hospital admissions (OR 0.13), reduced mortality (OR 0.29), and improved exercise capacity (60–215 m) and HRQoL
ACP/ACCP/ATS/ERS guideline (Qaseem et al 2011)	Recommend PR for symptomatic patients with FEV1 <50% predicted (strong recommendation)
Cochrane review (Dowman et al 2014)	PR improved 6-minute walk distance (WMD 44.34 m) and VO2 peak in ILD; evidence low–moderate
Morano et al (2013)	Preoperative PR vs chest PT: 6MWT improved from 425.5 ±85.3 m to 475 ±86.5 m (p<0.05) and lower post-op respiratory morbidity
Lai et al (2017)	Pre-op 1-week high-intensity program: between-group 6MWD difference 18.7 m (95% CI: 8.8–28.6; p<0.001), fewer PPCs and shorter LOS
Zhou et al (2020)	Peri-operative comprehensive PR associated with reduced postoperative pulmonary complications (OR = 0.655) and shorter post-op LOS
Mao et al (2021) systematic review/meta-analysis	Pooled OR for postoperative pulmonary complications 0.39 (95% CI: 0.27–0.56); PR reduced overall post-op complications
Nopp et al (2022) — long COVID cohort	6-week individualized PR improved 6MWD by mean 62.9 m (±48.2; p<0.001) and improved functional status, dyspnea, fatigue, and QOL

Scope & references

Scope summaryDefines medical necessity, limitations, exclusions, coding, documentation, functional thresholds, duration expectations and candidate selection for outpatient pulmonary rehabilitation programs.

Definitions

Very severe pulmonary impairment: Dyspnea at rest, difficulty in conversation (one-word answers), inability to work, cessation of most or all usual activities making the patient housebound, often limited to bed or chair with dependency for most activities of daily living (ADLs).

Revision History

03/15/2023reviewLatest

Last policy review on 03/15/2023; policy notes typical course up to 6 weeks or 36 hours and includes program guidance, documentation and coding criteria; next review scheduled for 01/11/2024. Marked non-material: No clinical policy statement changes noted in this part of the document.