ModifiedAmbetter NevadaPolicy CP.MP.176

Outpatient Cardiac Rehabilitation

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Medical necessity guidelines for conventional and intensive outpatient phase II cardiac rehabilitation programs for members of Ambetter Nevada (Centene-affiliated health plans). Applies to providers requesting coverage for supervised outpatient cardiac rehabilitation services.

Policy Summary

PayerAmbetter Nevada

PolicyOutpatient Cardiac Rehabilitation

Policy CodePolicy CP.MP.176

Change TypeMaterial edits to indications and contraindicationsclarified phase III/IV stance

Effective Date

Next Review Date

Key ActionObtain prior authorization for outpatient phase II cardiac rehabilitation and document indication, physician‑prescribed exercise each session, ECG monitoring, and that request is ≤36 visits over ≤9 months.

SourceLink

POLICY UPDATE CHANGES

Added 'Surgical septal myectomy via thoracotomy within last 12 months' to the list of indications (I.A).

Removed uncontrolled diabetes from the list of contraindications and removed requirement that if diabetic documentation supports that it is adequately controlled.

Edited contraindications: replaced 'Significant' with 'Symptomatic severe' aortic stenosis; added 'with hemodynamic compromise' to uncontrolled arrhythmias; added Active endocarditis and Acute aortic dissection; removed certain prior metabolic and blood pressure items.

Stated that phase III or IV cardiac rehab programs are not medically necessary because they are primarily educational or training programs.

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ModifiedAmbetter NevadaPolicy CP.MP.176

Outpatient Cardiac Rehabilitation

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Policy Summary

PayerAmbetter Nevada

PolicyOutpatient Cardiac Rehabilitation

Policy CodePolicy CP.MP.176

Change TypeMaterial edits to indications and contraindicationsclarified phase III/IV stance

Effective Date

Next Review Date

SourceLink

POLICY UPDATE CHANGES

Added 'Surgical septal myectomy via thoracotomy within last 12 months' to the list of indications (I.A).

Removed uncontrolled diabetes from the list of contraindications and removed requirement that if diabetic documentation supports that it is adequately controlled.

Stated that phase III or IV cardiac rehab programs are not medically necessary because they are primarily educational or training programs.

≤36maximum approved phase II visits

≤9 monthsmaximum approved period

93798covered CPT code

93797,G0422,G0423,S9472codes not supporting coverage

40+references cited

2018document ownership year

Coverage and Medical Necessity Criteria

Initial Therapy (Phase II)

Covered when ALL of the following are met

I. Initiation of phase II outpatient cardiac rehabilitation

I.A Indications: One of the following: stable angina pectoris within last 12 months; percutaneous coronary intervention within last 12 months; myocardial infarction within last 12 months; coronary artery bypass graft (CABG) within last 12 months; coronary artery disease within last six months; New York Heart Association (NYHA) Class II, III, or IV on a stable medication regimen; heart or heart-lung transplantation within last six months or within six months of newly gained ability to participate; cardiac valve surgery within last six months; peripheral artery disease within last 12 months; history of sustained ventricular tachycardia or fibrillation, or survivors of sudden cardiac death; surgical septal myectomy via thoracotomy within last 12 months.
I.B Therapy program requirements: Physician-prescribed exercise during each session AND electrocardiogram monitoring.
I.C Visit/Duration: Request is for ≤ 36 visits over a period of ≤ nine months.
I.D Contraindications: None of the following: unstable angina; orthostatic blood pressure drop >20 mmHg with symptoms; symptomatic severe aortic stenosis (aortic valve area <1.0 cm2); uncontrolled atrial or ventricular arrhythmias with hemodynamic compromise; decompensated heart failure; active pericarditis or myocarditis; active pulmonary embolism, pulmonary infarction or deep vein thrombosis; acute thrombophlebitis; acute systemic illness or fever; unstable or life-threatening noncardiovascular conditions (e.g., active infection, uncontrolled diabetes [removed in revisions], end-stage cancer, unstable psychological issues); severe orthopedic conditions prohibiting exercise; active endocarditis; acute aortic dissection.

Phase III/IV — Not Medically Necessary

III. Phase III or IV cardiac rehabilitation: Not medically necessary because these are primarily educational or training programs.

Intensive Cardiac Rehabilitation (ICR)

IV. Intensive Cardiac Rehabilitation (ICR): There is insufficient evidence that intensive cardiac rehabilitation (ICR) programs achieve superior outcomes compared to conventional cardiac rehabilitation programs. CMS criteria for qualifying ICR programs are noted in guidance and require demonstration of specified outcomes in peer-reviewed literature.

Phase III and Phase IV cardiac rehabilitation programs are considered not medically necessary under this policy because they are primarily educational or training programs rather than supervised outpatient rehabilitation that meets the policy's medical necessity requirements.

This clinical policy is provided as a guide to medical necessity to assist in coverage decisions and administration of benefits; it does not constitute a contract, payment guarantee, or override coverage document exclusions, limitations, or applicable state and federal requirements. Providers remain responsible for exercising professional medical judgment and must follow contractual terms, state Medicaid provisions when applicable, and any legal or regulatory requirements.

Services billed with CPT code 93797, HCPCS codes G0422 or G0423, or code S9472 do not meet the coverage criteria in this policy and therefore do not support medical necessity for outpatient cardiac rehabilitation. Because phase III/IV programs are explicitly deemed not medically necessary, claims billed with these codes are at risk for denial; providers should bill using codes and documentation that align with the policy’s covered services (for example, CPT 93798 when continuous ECG monitoring and other coverage criteria are met).

Coding and Billing Codes

Codes that support coverage criteriaCPTCovered

93798

Physician or other qualified health care professional services for outpatient cardiac rehabilitation; with continuous ECG monitoring (per session)

Codes that do not support coverage criteriamixedNot Covered

93797	Physician or other qualified health care professional services for outpatient cardiac rehabilitation; without continuous ECG monitoring (per session)
G0422	Intensive cardiac rehabilitation; with or without continuous ECG monitoring with exercise, per session
G0423	Intensive cardiac rehabilitation; with or without continuous ECG monitoring; without exercise, per session
S9472	Cardiac rehabilitation program, non-physician provider, per diem

Provider Requirements, Prior Authorization, and Billing Risks

Prior Authorization

Prior Authorization Required

Prior authorization is required for outpatient phase II cardiac rehabilitation. Submit documentation supporting medical necessity, including indication, physician-prescribed exercise for each session, and ECG monitoring. Requests for continuation or additional visits beyond the initial approval (total > 36 visits or > nine months) will be reviewed by a medical director and may be denied if criteria are not met.

Prior authorization required for phase II outpatient cardiac rehabilitation
Requests for additional visits beyond 36 visits or beyond nine months require medical director review

Note

Prior Authorization and Coverage Review Note

Review applicable Medicare NCDs, LCDs, Medicare Coverage Articles, and state Medicaid manuals before applying this policy; this policy is a clinical guidance document and does not guarantee coverage. Coverage decisions are subject to the terms, conditions, exclusions and limitations of the member's benefit documents and applicable state/federal requirements.

Review CMS NCDs/LCDs and Medicare Coverage Articles prior to applying criteria

Definitions and Program Types

Phase II outpatient CR — definition/description

DefinitionOutpatient Phase II cardiac rehabilitation: a supervised, physician-prescribed program of monitored exercise training with electrocardiogram (ECG) monitoring provided after qualifying cardiac events or procedures to optimize function and secondary prevention.

Typical componentsIncludes medical evaluation/baseline assessment, physician-prescribed exercise each session, ECG monitoring, coronary risk-factor reduction, nutrition counseling, psychosocial support, and education on diet, medications and exercise tolerance.

Indications timeframe (examples)Common qualifying events include recent myocardial infarction, percutaneous coronary intervention, or CABG within the prior 12 months and other cardiac surgeries or transplants within relevant post-operative windows as specified in coverage criteria.

Visit/Duration limitsAuthorization and coverage are framed around ≤36 outpatient Phase II visits over a period of ≤9 months; requests beyond these limits require medical director review.

Intensive cardiac rehabilitation (ICR) — definition/description

Background and Scope

Cardiac rehabilitation (CR) is a coordinated, multifaceted program that typically includes medical evaluation, monitored exercise training, risk-factor modification, nutrition counseling, psychosocial support, and patient education. CR has been shown to reduce mortality, myocardial infarction, and hospital readmissions while improving exercise tolerance and quality of life; benefits are observed in patients with coronary heart disease and heart failure.

Policy Summary

PayerAmbetter Nevada

PolicyOutpatient Cardiac Rehabilitation

Policy CodePolicy CP.MP.176

Change TypeMaterial edits to indications and contraindicationsclarified phase III/IV stance

Effective Date

Next Review Date

SourceLink

On This Page

For Medicaid members, state Medicaid coverage provisions take precedence and the state Medicaid manual should be consulted

Coverage subject to member benefit documents, exclusions, and applicable laws/regulations

Denial Risk

Coding-Related Denial Risks

Requests coded with services that do not meet the policy's monitoring requirement may be denied. Specifically, claims billed with CPT 93797 (without continuous ECG monitoring), HCPCS G0422, G0423, or S9472 do not support coverage under this policy and may be denied.

CPT 93797 — outpatient cardiac rehabilitation without continuous ECG monitoring (may be denied)
G0422, G0423 — intensive cardiac rehabilitation codes (may be denied)
S9472 — cardiac rehabilitation program, non-physician provider, per diem (may be denied)

Step Therapy

No step therapy rules are specified for cardiac rehabilitation in this policy. Providers should follow the prior authorization and documentation requirements described elsewhere in this section and the policy.

No step therapy requirements specified

Documentation Required

Required Session Documentation

Support each session with documentation of physician-prescribed exercise and continuous ECG monitoring as applicable, and retain records demonstrating progress toward treatment goals and adherence to home exercise program for continuation requests.

Document physician-prescribed exercise during each session
Document ECG monitoring during sessions
Maintain records of symptom reduction, functional improvement, and home program adherence for continuation requests

DefinitionIntensive cardiac rehabilitation (ICR): a physician-supervised program that furnishes cardiac rehabilitation services more frequently and often in a more rigorous manner than conventional programs; qualifying ICR must demonstrate specific outcomes in peer-reviewed literature (e.g., affect CHD progression, reduce need for CABG or PCI).

Program examplesEstablished commercial ICR programs include the Pritikin Program, the Ornish Program for Reversing Heart Disease, and the Benson-Henry Institute Cardiac Wellness Program.

Required evidence to qualifyICR programs must demonstrate in peer‑reviewed literature at least one qualifying outcome: positively affect coronary heart disease progression, reduce need for coronary bypass surgery, or reduce need for percutaneous coronary interventions.

Policy stanceThe policy notes insufficient evidence that ICR achieves superior outcomes compared with conventional CR and therefore does not broadly endorse ICR as superior to standard Phase II programs.

Cardiac rehabilitation — structured exercise, risk-factor modification and secondary prevention programs

DefinitionCardiac rehabilitation (CR): structured programs combining supervised exercise training, risk‑factor modification, and secondary prevention interventions to optimize physical, psychological, and social functioning and reduce morbidity and mortality in patients with coronary heart disease and selected cardiac conditions.

Core elementsMedical evaluation and baseline assessment, monitored exercise training, coronary risk factor reduction (including nutrition and weight management), psychosocial support, and education on diet, medications and exercise tolerance.

Clinical benefitsSystematic reviews and guidelines report reductions in mortality, myocardial infarction, and hospital readmissions, and improvements in exercise capacity and health‑related quality of life for CHD and heart failure populations.

Guideline sourcesDefinitions and standards derive from professional guidance including the AHA/ACC, AACVPR, Cochrane reviews, and exercise testing/training statements referenced in the policy.