Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • NPI Medicare & Medicaid
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.28
    OpenPayerPolicy UpdatesCardiologyBCBS Massachusetts cardiac rehabilitation Coverage…
    Ask Trek AI about this page
    CurrentBlue Cross Blue Shield - MassachusettsPolicy 916

    916_cardiac_rehabilitation_policy

    Customize your policy alerts

    Sign up for Blue Cross Blue Shield - Massachusetts Policy 916 alerts

    Get alerted when Policy 916 changes without checking for updates manually.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    Defines medical necessity criteria, investigational indications, prior authorization rules, and coding for outpatient cardiac rehabilitation services for commercial members of Blue Cross Blue Shield Massachusetts.

    Policy Summary
    PayerBlue Cross Blue Shield - Massachusetts
    Policy916_cardiac_rehabilitation_policy
    Policy CodePolicy 916
    Change TypeAnnual reviewinvestigational addition (virtual CR)
    Effective DateMay 1, 2025
    Last ReviewMay 1, 2025
    Next Review Date
    Key ActionPrecertification/preauthorization is required for inpatient services described in this policy; for outpatient services prior authorization is not required for Commercial PPO and Indemnity products.
    SourceLink

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    POLICY UPDATE CHANGES

    5/2025 annual policy review: Summary and references updated. Policy statements unchanged.

    8/2023 added investigational policy statement for virtual cardiac rehabilitation.

    1/2021 outpatient pediatric cardiac rehabilitation left to discretion of referring/ordering provider.

    6Covered Indications (listed)
    5Investigational/Not Covered Programs Listed
    3Primary CPT/HCPCS Codes Referenced

    Coverage Summary

    Defines medical necessity, investigational indications, prior authorization rules, and coding for outpatient cardiac rehabilitation for commercial members. Policy applies to adults with coronary heart disease, recent myocardial infarction, revascularization (PCI/stent or CABG), heart valve surgery, heart or heart‑lung transplantation, current stable angina, and compensated heart failure. Coverage stance is mixed (standard outpatient cardiac rehabilitation: medically necessary for listed indications; intensive and virtual programs: investigational/not covered). Effective date: 2025-05-01; Last review: 2025-05-01.

    Key Facts
    Policy number916
    SubjectOutpatient Cardiac Rehabilitation
    Effective date2025-05-01
    Last review2025-05-01
    Coverage stanceMixed (medically necessary for listed indications; investigational/not covered for intensive and virtual CR/repeat participation)
    PayerBlue Cross Blue Shield - Massachusetts

    Medical-Necessity Criteria

    Medically Necessary Outpatient Cardiac Rehabilitation

    Outpatient cardiac rehabilitation programs are considered MEDICALLY NECESSARY for individuals with a history of ANY of the following:

    Medically Necessary Outpatient Cardiac Rehabilitation - qualifying events

    • Acute myocardial infarction (heart attack) within the preceding 12 months
    • Percutaneous transluminal coronary angioplasty or coronary stenting
    • Coronary artery bypass surgery graft
    • Heart valve surgery
    • Current stable angina pectoris OR heart or heart-lung transplantation

    Coding

    Covered CPTCPTCovered
    93797Physician services for outpatient cardiac rehab; without continuous ECG monitoring (per session)
    93798Physician services for outpatient cardiac rehab; with continuous ECG monitoring (per session)
    Covered HCPCS (non-physician)HCPCSCovered
    S9472Cardiac rehabilitation program - non-physician provider - per diem
    Investigational HCPCS (Intensive Cardiac Rehabilitation)HCPCSNot Covered
    G0422Intensive cardiac rehabilitation; with or without continuous ECG monitoring with exercise, per session
    G0423Intensive cardiac rehabilitation; with or without continuous ECG monitoring; without exercise, per session
    Relevant ICD-10 Diagnosis Codes (listed as medically necessary when submitted with CPT/HCPCS if criteria met)ICD-10Covered
    I20.1Angina pectoris with documented spasm
    I20.2Refractory angina pectoris
    I20.8Other forms of angina pectoris
    I20.9Angina pectoris, unspecified
    I21.01ST elevation (STEMI) myocardial infarction involving left main coronary artery
    I21.02ST elevation (STEMI) myocardial infarction involving left anterior descending coronary
    I21.09ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior
    I21.11ST elevation (STEMI) myocardial infarction involving right coronary artery
    I21.19ST elevation (STEMI) myocardial infarction involving other right coronary artery
    I21.29ST elevation (STEMI) myocardial infarction involving other sites
    1–10 of 88
    1/9

    Provider Actions

    Prior Authorization

    Precertification/Preauthorization required for inpatient services

    Precertification/preauthorization IS REQUIRED for services described in this policy if the procedure is performed inpatient.

    Prior Authorization

    Outpatient prior authorization not required for certain products

    For outpatient services, prior authorization is not required for Commercial PPO and Indemnity products (policy notes indicate outpatient prior authorization is not required for these product types).

    Documentation Required

    Submission of ICD-10 with CPT/HCPCS

    ICD-10 diagnosis codes listed must be submitted with the CPT and HCPCS codes above when medical necessity criteria are met; providers should report services using up-to-date procedure, revenue, and diagnosis codes including modifiers as applicable.

    Background & Evidence

    Cardiac rehabilitation (CR) is a comprehensive, medically supervised outpatient program that includes medical evaluation, prescribed exercise, cardiac risk‑factor modification, education, and counseling aimed at limiting the physiologic and psychological effects of cardiac illness and preventing recurrent events. National and specialty societies (U.S. Public Health Service, American Heart Association, European Association of Cardiovascular Prevention and Rehabilitation, Heart Failure Society of America) endorse CR for patients with coronary heart disease and heart failure and have defined core program components. Randomized controlled trials and systematic reviews/meta‑analyses demonstrate that exercise‑based outpatient CR improves outcomes for selected patients—particularly those with coronary heart disease, heart failure, and post‑cardiac surgery—supporting the policy’s medically necessary designation for those indications. Evidence is limited or insufficient for repeat participation without a new qualifying event and for intensive programs (Ornish, Pritikin, Benson‑Henry) and virtual CR with respect to hospitalization or mortality, which the policy therefore considers investigational.

    Evidence Summary
    Net health outcome for standard outpatient CREvidence sufficient to determine improvement in net health outcome for select patients (coronary heart disease, heart failure, post-surgical)
    Repeat participationInsufficient evidence — no trials identified; repeat participation without a new qualifying event considered investigational
    Intensive CR (Ornish, Pritikin, Benson-Henry)

    Definitions

    Compensated heart failure: Term used in the policy to indicate heart failure that is clinically stable/compensated; specific clinical parameters are not defined in the policy text.

    Intensive cardiac rehabilitation (ICR): Programs such as the Ornish, Pritikin, and Benson‑Henry Institute programs that include intensive lifestyle modification; the policy designates these programs investigational.

    Medicare Determinations

    NumberNameEffective DateType
    20.10NCD Cardiac Rehabilitation Programs2014-09NCD
    20.10.1NCD Cardiac Rehabilitation Programs for Chronic Heart Failure2014-09NCD

    Revision History

    1/2021clarification

    Policy clarified: outpatient pediatric cardiac rehabilitation for congenital heart disease is left to the discretion of the referring and/or ordering provider; Medicare-specific information removed.

    8/2023added

    Added investigational policy statement: virtual cardiac rehabilitation is considered INVESTIGATIONAL. (Highlighted: material change)

    5/2025annual_reviewLatest
    Policy Summary
    PayerBlue Cross Blue Shield - Massachusetts
    Policy916_cardiac_rehabilitation_policy
    Policy CodePolicy 916
    Change TypeAnnual reviewinvestigational addition (virtual CR)
    Effective DateMay 1, 2025
    Last ReviewMay 1, 2025
    Next Review Date
    Key ActionPrecertification/preauthorization is required for inpatient services described in this policy; for outpatient services prior authorization is not required for Commercial PPO and Indemnity products.
    SourceLink
    On This Page
    Coverage SummaryMedical-Necessity CriteriaCodingProvider ActionsBackground & EvidenceDefinitionsMedicare DeterminationsRevision History

    policy text lists 'Current stable angina pectoris OR Heart or heart-lung transplantation' on one bullet

  1. Compensated heart failure

    2. Container

    Not Medically Necessary / Investigational

    The following are considered investigational or not supported by medical necessity:

    Not Medically Necessary / Investigational items

    • Repeat participation in an outpatient cardiac rehabilitation program in the absence of another qualifying cardiac event is considered INVESTIGATIONAL.
    • Intensive cardiac rehabilitation with the Ornish Program for Reversing Heart Disease is considered INVESTIGATIONAL.
    • Intensive cardiac rehabilitation with the Pritikin Program is considered INVESTIGATIONAL.
    • Intensive cardiac rehabilitation with the Benson-Henry Institute Program is considered INVESTIGATIONAL.
    • Virtual cardiac rehabilitation is considered INVESTIGATIONAL.
    • HCPCS codes G0422 and G0423 (Intensive cardiac rehabilitation) are considered investigational for Commercial Members.

    Container

    Special Population / Discretionary Coverage

    The policy position for pediatric outpatient cardiac rehabilitation:

    Special Population / Discretionary Coverage: Outpatient pediatric cardiac rehabilitation program for heart diseases including congenital heart disease is left to the discretion of the referring and/or ordering provider.
    • 93797
    • 93798
    • S9472
    Insufficient evidence to determine improvement in net health outcome; considered investigational/not covered
    Virtual cardiac rehabilitationMeta-analyses show benefits for physical activity and quality of life but insufficient evidence for hospitalization or mortality; considered investigational

    Annual policy review: Summary and references updated; policy statements unchanged.