Outpatient Cardiac Rehabilitation
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Medical necessity guidelines for initiation and continuation of phase II outpatient cardiac rehabilitation and the policy stance on phase III/IV and intensive cardiac rehabilitation programs for members of Arizona Complete Health (Centene-affiliated health plans). Applies to providers submitting requests for outpatient cardiac rehabilitation services.
No material clinical or coverage changes in this revision.
Coverage Criteria for Cardiac Rehabilitation
Initiation of Phase II Outpatient Cardiac Rehabilitation
Covered when ALL of the following are met:
Initiation criteria
- Indications: One of: 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; 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
(List extracted verbatim)
- Therapy program requirements: Both: Physician-prescribed exercise during each session; Electrocardiogram monitoring
Must be documented
- Request limits: Request is for ≤ 36 visits over a period of ≤ nine months≤36 visits; ≤9 months
Requests beyond will be reviewed
- Contraindications (must NOT be present): Any of: Unstable angina; Orthostatic blood pressure drop of >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 (active infection, uncontrolled diabetes, end-stage cancer, or unstable psychological issues); Severe orthopedic conditions that would prohibit exercise; Active endocarditis; Acute aortic dissection
Presence of any listed contraindication excludes initiation
Phase III/IV Cardiac Rehabilitation
These programs are considered primarily educational or training programs
Intensive Cardiac Rehabilitation (ICR) stance
ICR programs (eg, Ornish, Pritikin, Benson-Henry) are described; CMS requires demonstration of specified clinical outcomes to qualify
Phase III and IV cardiac rehabilitation programs are considered not medically necessary by the plan because they are primarily educational or training programs and therefore are excluded from coverage.
State Medicaid coverage provisions may supersede this clinical policy; when there is a conflict between this policy and applicable state Medicaid rules, the state provisions will take precedence.
Phase III or IV cardiac rehabilitation programs that are delivered primarily as educational or training programs are not medically necessary and are excluded from coverage under this policy.
No additional explicit exclusions are listed in the provided sections of this policy; coverage decisions remain subject to the member’s contract terms, applicable state and federal requirements, and other plan provisions.
CPT/HCPCS Codes and Billing Guidance
| 93798 | Physician or other qualified health care professional services for outpatient cardiac rehabilitation; with continuous ECG monitoring (per session) |
| 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 |
| No codes listed |
Provider Requirements, Prior Authorization, and Documentation
Prior authorization required; bill using CPT 93798
Prior authorization is required for requests for Phase II outpatient cardiac rehabilitation that meet the policy indications; submit requests using the CPT code that supports coverage (93798 — with continuous ECG monitoring). CPT 93797, G0422, G0423, and S9472 do not support coverage under this policy and should not be billed when seeking coverage under these criteria.
- Prior authorization required when initiation/continuation criteria are met (see policy indications and therapy program requirements).
- Bill covered sessions with CPT 93798 (continuous ECG monitoring per session).
- Do not use 93797, G0422, G0423, or S9472 to meet the coverage-supported service code for Phase II under this policy.
Review applicable Medicare NCDs/LCDs/Coverage Articles
For Medicare members/enrollees, providers and reviewers should review all applicable Medicare National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Medicare Coverage Articles on the CMS website before applying this clinical policy.
- Consult CMS (http://www.cms.gov) for current NCDs, LCDs, and Coverage Articles that may affect coverage determinations.
No step therapy required
No step therapy requirements are specified in the sections of this clinical policy.
Document physician‑prescribed exercise and ECG monitoring per session
For each covered Phase II outpatient cardiac rehabilitation session, document that exercise was physician‑prescribed and that electrocardiogram monitoring occurred during the session.
- Record physician prescription for exercise for every session.
- Document ECG monitoring during each session as part of the therapy program requirements.
Document services consistent with plan coverage and contract terms
Document services consistent with the Health Plan's coverage decisions, the member's contract terms and conditions, and applicable state and federal requirements; this policy is a guide and not a guarantee of payment.
- Ensure documentation meets Health Plan and contract requirements and applicable state/federal rules.
- Retention of supporting clinical records may be necessary to substantiate medical necessity and payment.
Requests >36 visits or >9 months subject to denial and medical director review
Requests that exceed 36 visits or cover a period longer than nine months may be denied; requests for additional visits or extended periods will be reviewed by the medical director.
- Initial and total approved requests should not exceed 36 visits or a nine‑month period.
- Submit justification for any request beyond these limits; such requests will undergo medical director review and may be denied.
Medicare coverage denial risk if CMS guidance not followed
Failure to follow applicable Medicare NCDs, LCDs, and Coverage Articles may result in denial of coverage for Medicare members; reviewers are instructed to consult CMS guidance prior to applying this policy.
- Noncompliance with Medicare coverage determinations can lead to denied claims for Medicare enrollees.
State Medicaid provisions take precedence; Medicaid denial risk if not followed
When state Medicaid coverage provisions conflict with this clinical policy, the state Medicaid provisions take precedence; failure to follow applicable state Medicaid rules may risk denial for Medicaid members.
- Refer to the state Medicaid manual for coverage provisions that may supersede this policy.
Definitions and Program Descriptions
Background
Cardiac rehabilitation (CR) is a multidisciplinary program that typically includes supervised exercise, risk-factor reduction, nutritional counseling, psychosocial support, and patient education. These components work together to improve exercise capacity, reduce symptoms, lower rehospitalization and mortality risk, and enhance quality of life for patients with coronary disease, heart failure, or after cardiac procedures.
For outpatient Phase II programs specifically, services are usually electrocardiogram-monitored and supervised by clinicians, tailored to the individual patient, and commonly delivered two to three times weekly for eight to 12 weeks or longer; sessions should include physician-prescribed exercise and ECG monitoring documented per session.
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