CurrentBlue Cross Blue Shield - MassachusettsPolicy 916

916_cardiac_rehabilitation_policy

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 review; investigational addition (virtual CR)

Effective DateMay 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.

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

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.

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.

Coding

Covered CPTCPTCovered

93797	Physician services for outpatient cardiac rehab; without continuous ECG monitoring (per session)
93798	Physician services for outpatient cardiac rehab; with continuous ECG monitoring (per session)

Covered HCPCS (non-physician)HCPCSCovered

S9472

Cardiac rehabilitation program - non-physician provider - per diem

Investigational HCPCS (Intensive Cardiac Rehabilitation)HCPCSNot Covered

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

Relevant ICD-10 Diagnosis Codes (listed as medically necessary when submitted with CPT/HCPCS if criteria met)ICD-10Covered

I20.1	Angina pectoris with documented spasm
I20.2	Refractory angina pectoris
I20.8	Other forms of angina pectoris
I20.9	Angina pectoris, unspecified
I21.01	ST elevation (STEMI) myocardial infarction involving left main coronary artery
I21.02	ST elevation (STEMI) myocardial infarction involving left anterior descending coronary
I21.09	ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior
I21.11	ST elevation (STEMI) myocardial infarction involving right coronary artery
I21.19	ST elevation (STEMI) myocardial infarction involving other right coronary artery
I21.29	ST 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.

93797
93798
S9472

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)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

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.

Number	Name	Effective Date	Type
20.10	NCD Cardiac Rehabilitation Programs	2014-09	NCD
20.10.1	NCD Cardiac Rehabilitation Programs for Chronic Heart Failure	2014-09	NCD

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

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

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

Policy916_cardiac_rehabilitation_policy

Policy CodePolicy 916

Change TypeAnnual review; investigational addition (virtual CR)

Effective DateMay 1, 2025

Next Review Date

On This Page

OpenPayer

916_cardiac_rehabilitation_policy

Coverage Summary

Medical-Necessity Criteria

Coding

Provider Actions

Background & Evidence

Definitions

Medicare Determinations

Revision History