CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Cardiac Rehabilitation (including Intensive Cardiac Rehabilitation) Coverage Criteria

Policy governing coverage and coding for outpatient cardiac rehabilitation and intensive cardiac rehabilitation programs for Blue Cross Blue Shield - Rhode Island members.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyCardiac Rehabilitation (including Intensive Cardiac Rehabilitation) Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionNo prior authorization is required for cardiac rehabilitation services per this policy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

93797/93798/G0422/G0423Covered codes

Maintenance programsNot covered (all products)

99078Not reimbursed separately

Per episodeBenefit limit

Coverage Criteria

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Qualifying events/conditions: Acute myocardial infarction within the preceding 12 months; coronary artery bypass surgery; current stable angina pectoris; percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting; heart valve repair or replacement; heart or heart-lung transplant; stable, chronic heart failure meeting defined criteriasee Background and Definitions

A new cardiac episode or change in condition may qualify a patient for an additional series of rehabilitation

ICR Program Requirements

ICR is covered when the program meets CMS-defined evidence requirements.

ICR evidence and program approval: Program must show peer-reviewed published research demonstrating one or more specified patient-level benefits (positively affected progression of coronary heart disease; reduced need for coronary bypass surgery; reduced need for percutaneous coronary interventions) AND must demonstrate improvements in specified risk factors (LDL, triglycerides, BMI, systolic and diastolic blood pressure, and reduced need for cholesterol, blood pressure, and diabetes medications). Individual programs must be approved through the national coverage determination process.CMS NCD requirements

CMS has determined the Ornish, Pritikin, and Benson-Henry programs meet ICR requirements

Maintenance cardiac rehabilitation programs that follow the initial rehabilitation program are not covered for all products. Coverage and applicability vary by product type; providers should verify member benefits and eligibility in the member's Benefit Booklet/Evidence of Coverage/Subscriber Agreement before delivering or billing for maintenance services.

Educational services (CPT 99078), including counseling on nutrition, lipid management, stress management, lifestyle changes and similar group education, are considered part of the cardiac rehabilitation program and are not separately reimbursed for all products. Services that are determined to be not medically necessary, or that are not covered under the member's subscriber agreement, may not be payable and should not be billed to the member unless there is a prior written agreement. Providers must confirm coverage and any member liability with the member's Benefit Booklet/Evidence of Coverage/Subscriber Agreement.

Coding and Billing

Covered CPT Codes (Cardiac rehabilitation)CPTCovered

93797	Physician or other qualified health care professional services for outpatient cardiac rehabilitation; without continuous ECG monitoring (per session)
93798	Physician or other qualified health care professional services for outpatient cardiac rehabilitation; with continuous ECG monitoring (per session)

ICR HCPCS/HCPCS-like codes (not applicable for Commercial claims per policy guidance)HCPCSCovered

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

Not separately reimbursedCPTNot Covered

99078

Educational services rendered to patients in a group setting — not separately reimbursed

inv-08: Left ventricular ejection fraction (LVEF) — threshold detail

LVEF thresholdLeft ventricular ejection fraction ≤35%

ContextApplies to stable, chronic heart failure patients for cardiac rehabilitation coverage

Source effective dateCMS determination effective for dates of service on and after February 18, 2014

inv-09: NYHA class — clinical threshold/description

NYHA class requirementNew York Heart Association (NYHA) class II–IV symptoms

Therapy requirementSymptoms persist despite optimal heart failure therapy for at least 6 weeks

ApplicabilityUsed with LVEF ≤35% to define stable chronic heart failure eligible for cardiac rehab coverage

Provider Actions & Billing Guidance

Prior Authorization

No prior authorization is required for cardiac rehabilitation services per this policy.

Note

Documentation Required

Benefit Verification and Documentation

Providers should refer to the member's Benefit Booklet/Evidence of Coverage/Subscriber Agreement for benefit limits and eligibility. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement; those documents supersede this medical policy.

Confirm member-specific benefits and eligibility prior to scheduling services.
When services are denied as not medically necessary or noncovered, follow member billing rules in the subscriber agreement; obtain written member agreement before billing the member.

Denial Risk

Coverage Exclusions and Billing Risk

Maintenance cardiac rehabilitation programs following the initial rehabilitation program are not covered for all products; confirm coverage before providing or billing for maintenance services. Education and counseling services that are part of the cardiac rehabilitation program (nutrition, lipid management, stress management, lifestyle counseling including daily exercise) are included in the program and are not separately reimbursed for all products.

Maintenance cardiac rehabilitation: not covered for some Medicare Advantage and commercial products.
Do not bill separately for education/counseling components that are integral to the cardiac rehabilitation program.

Background

Cardiac rehabilitation is a comprehensive, medically supervised outpatient program designed to improve functional capacity, reduce cardiovascular risk factors, and help prevent future cardiac events. It is commonly indicated after qualifying events such as acute myocardial infarction (typically within 12 months), coronary artery bypass grafting, percutaneous coronary intervention or stenting, valve repair or replacement, heart or heart–lung transplant, and for selected patients with stable chronic heart failure who meet defined clinical criteria. Programs may include monitored exercise, risk-factor modification, education, and psychosocial support, delivered under physician supervision.

Definitions

inv-15: Stable chronic heart failure — Per CMS (effective Feb 18, 2014): patients with left ventricular ejection fraction ≤35% and NYHA class II-IV symptoms despite optimal heart failure therapy.

CMS stable chronic heart failure definitionPatients with LVEF ≤35% and NYHA class II–IV symptoms despite optimal heart failure therapy for at least 6 weeks

Stability criteriaNo recent (≤6 weeks) or planned (≤6 months) major cardiovascular hospitalizations or procedures

Coverage implicationMeets Medicare coverage determination for cardiac rehabilitation when criteria satisfied (effective Feb 18, 2014)

inv-16: Intensive Cardiac Rehabilitation (ICR) — A physician-supervised program providing more frequent and rigorous services than standard cardiac rehab; must show peer-reviewed evidence.

ICR program definitionPhysician‑supervised program providing more frequent and often more rigorous cardiac rehabilitation services than standard CR

Evidence requirementMust show in peer‑reviewed published research one or more patient‑level benefits (affect progression of coronary heart disease; reduced need for bypass surgery; reduced need for PCI)

Risk‑factor improvement requirementMust demonstrate improvements in LDL, triglycerides, BMI, systolic and diastolic BP, and reduced need for cholesterol, BP, or diabetes medications

Program approvalIndividual ICR programs must be approved through the national coverage determination process (CMS)