RetiredCapital BluecrossPolicy MP 8.005

Cardiac Rehabilitation in the Outpatient Setting

Defines medical necessity criteria, program components, and coding guidance for outpatient cardiac rehabilitation services provided to eligible patients under Capital Blue Cross products.

Policy Summary

PayerCapital Bluecross

PolicyCardiac Rehabilitation in the Outpatient Setting

Policy CodePolicy MP 8.005

Change TypeRetiredcoding and coverage updates

Effective DateRETIRED 9/1/2025

Next Review Date

Key ActionLimit outpatient cardiac rehabilitation to 3 sessions per week for up to 12 weeks (36 sessions) and document qualifying diagnosis and required program components.

SourceLink

POLICY UPDATE CHANGES

Medically necessary statement for virtual cardiac rehabilitation added to policy statement; policy guidelines updated; rationale updated; references updated; coding and table updated: G0422, G0423 moved to INV to align with policy statement.

Deleted 'recommended by a cardiologist' in first paragraph in policy statement.

Benson-Henry Institute Program added as investigational.

Policy retired.

36maximum covered sessions

90start window (days)

6completion timeframe (months)

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investigational codes

04/10/2025policy retired

Coverage Criteria

Initial eligibility — Outpatient cardiac rehabilitation

Outpatient cardiac rehabilitation programs may be considered medically necessary for individuals with any of the following:

Qualifying conditions/procedures: Acute myocardial infarction (within the preceding 12 months); coronary artery bypass graft surgery; percutaneous transluminal coronary angioplasty or coronary stenting; heart valve surgery; heart or heart-lung transplant; current stable angina pectoris; compensated heart failure.

Listed exactly as qualifying indications in policy.

Investigational / not covered uses

Repeat participation and alternative forms considered investigational:

Investigational: Repeat participation in outpatient cardiac rehabilitation without another qualifying cardiac event; intensive cardiac rehabilitation programs (Ornish, Pritikin, Benson-Henry Institute); virtual cardiac rehabilitation as an alternative to facility-based programs; outpatient cardiac rehabilitation for other indications (e.g., SARS-CoV-2).

Policy states insufficient evidence for these uses.

Coverage stance (procedures and diagnoses)

Summary coverage stance from the available sections in this portion of the document:

General coverage logic: Outpatient cardiac rehabilitation services listed by procedure code (for example 93798, 93797 and associated S/HCPCS codes) are covered when medically necessary for the listed cardiac diagnoses; intensive cardiac rehabilitation (G0422, G0423) is considered investigational and is not covered.

Coverage tied to procedure and diagnosis codes as listed in policy.

Coverage stance and historical criteria changes

Policy stance evolved over time to include virtual cardiac rehabilitation as medically necessary and to designate certain programs investigational.

policy_stance_history: Policy history documents: (1) deletion of 'recommended by a cardiologist' from the policy statement; (2) Benson-Henry Institute Program added as investigational; (3) new ICD-10-CM codes added in 2022 and 2023; (4) medically necessary statement for virtual cardiac rehabilitation added in 2023 and coding updated moving G0422/G0423 to investigational; (5) policy retired effective 04/10/2025.

Summary of documented policy edits and timeline from policy history.

Outpatient cardiac rehabilitation is considered investigational for indications beyond the policy’s listed qualifying cardiac events (for example, management of post-acute sequelae of SARS‑CoV‑2 infection). The policy states there is insufficient evidence to conclude that outpatient cardiac rehabilitation improves health outcomes for these other indications, and therefore such uses are investigational and not covered.

The policy also indicates that virtual cardiac rehabilitation has limited evidence when used as an alternative to facility‑based programs; prior reviews concluded the evidence is insufficient to support virtual CR as a general substitute for traditional outpatient cardiac rehabilitation.

The policy explicitly designates Intensive Cardiac Rehabilitation as investigational and not covered. Specifically, the HCPCS procedure codes G0422 and G0423 (Intensive cardiac rehabilitation) are listed as investigational and therefore excluded from coverage.

Policy history documents a coding update that moved G0422 and G0423 to investigational status to align with the policy statement; billing these codes may result in coverage denials under the updated coding table.

The policy names the Benson‑Henry Institute Program (along with Ornish and Pritikin programs) as an example of an intensive cardiac rehabilitation program considered investigational. As such, services specific to the Benson‑Henry Institute Program are explicitly excluded due to insufficient evidence of net health benefit.

Policy revision history documents the addition of the Benson‑Henry Institute Program to the investigational list during a minor review, reinforcing that this named program is not covered.

Physical therapy and occupational therapy provided concurrently with outpatient cardiac rehabilitation are not medically necessary when they are part of the cardiac rehabilitation program itself. These therapies are allowable only if they are performed for a separate, unrelated diagnosis and appropriately documented as medically necessary for that distinct condition.

Providers should ensure documentation clearly supports a separate medical necessity for PT/OT services billed in conjunction with cardiac rehabilitation to avoid denials.

The policy’s coding update moving intensive cardiac rehabilitation delivery codes to investigational means that the specific billing codes G0422 and G0423 are not considered covered under this policy. Claims submitted using these codes are subject to denial consistent with the investigational status.

The coding table change was made to align coding with the policy’s investigational designation for intensive cardiac rehabilitation; billing and prior authorization processes should reflect this update.

Coding and Billing

Intensive cardiac rehabilitation - not coveredHCPCSNot Covered

G0422	Intensive cardiac rehabilitation (not covered per policy text)
G0423	Intensive cardiac rehabilitation (not covered per policy text)

Covered when medically necessary (fragmented list)mixedCovered

93798	Cardiac rehabilitation; (document lists 93798 alongside multiple modifiers/procedure codes but text is fragmented)
S0341	Listed in coding section (context unclear due to fragmented text)
S0342	Listed in coding section (context unclear due to fragmented text)
S9472	Listed in coding section (context unclear due to fragmented text)
93015	Listed in coding section (context unclear due to fragmented text)
93016	Listed in coding section (context unclear due to fragmented text)
93017	Listed in coding section (context unclear due to fragmented text)
93018	Listed in coding section (context unclear due to fragmented text)
93797	Listed in coding section (context unclear due to fragmented text)

Investigational / Not Covered Procedure CodesHCPCSNot Covered

G0422	Intensive cardiac rehabilitation — not covered
G0423	Intensive cardiac rehabilitation — not covered

Covered when medically necessary (Procedure / HCPCS / CPT group)mixedCovered

93798	Cardiac rehabilitation; with continuous ECG monitoring
S0341	Related procedure/service (as listed)
S0342	Related procedure/service (as listed)
S9472	Related procedure/service (as listed)
93015	Cardiac testing/procedure (listed as associated)
93016	Cardiac testing/procedure (listed as associated)
93017	Cardiac testing/procedure (listed as associated)
93018	Cardiac testing/procedure (listed as associated)
93797	Cardiac rehabilitation without continuous ECG monitoring

Covered when medically necessary — Diagnosis CodesICD-10Covered

I20.1	Angina pectoris with documented spasm
I20.2	Refractory angina pectoris
I20.8	Other forms of angina pectoris
I20.81	Angina pectoris with coronary microvascular dysfunction
I20.89	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 artery
I21.09	ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall
I21.A1	Myocardial infarction type 2

1–10 of 84

1/9

Investigational/changed codesCPTExperimental

G0422	Outpatient cardiac rehabilitation; delivery code moved to investigational in coding table
G0423	Outpatient cardiac rehabilitation; delivery code moved to investigational in coding table

Added ICD-10-CM codesICD-10

I20.81	New ICD-10-CM code added to policy
I20.89	New ICD-10-CM code added to policy
I21.B	New ICD-10-CM code added to policy

Provider Actions and Operational Guidance

Billing Rule

Procedure codes requiring medical necessity

Specific procedure codes are covered only when medical necessity is documented in the record. Ensure claims for outpatient cardiac rehabilitation include the appropriate procedure codes (eg, 93798 and associated HCPCS/S codes listed in the coding table) and that medical record documentation supports the need for cardiac rehabilitation for the member's qualifying diagnosis or event.

Covered procedure codes (examples): 93798 and associated HCPCS/S codes (see coding table).
Ensure medical necessity documentation is present on the chart and matches billed codes.

Denial Risk

Investigational coding moved (G‑codes)

Intensive cardiac rehabilitation procedure codes G0422 and G0423 have been moved to investigational (not covered) status. Do not bill these G‑codes for covered outpatient cardiac rehabilitation services.

Background

Cardiac rehabilitation refers to comprehensive, medically supervised outpatient programs designed to improve functional capacity and reduce risk of future cardiac events. Core program components include physician‑prescribed exercise on days services are delivered, cardiac risk‑factor modification, psychosocial assessment, outcomes assessment, and an individualized treatment plan.

The policy specifies coverage limits of 3 sessions per week, up to 12 weeks (maximum 36 sessions); programs should start within 90 days of the qualifying cardiac event and be completed within 6 months of the event.

While outpatient cardiac rehabilitation is covered for listed qualifying conditions (for example, recent myocardial infarction, CABG, PCI/stenting, valve surgery, transplant, stable angina, or compensated heart failure), the policy designates repeat participation without a new qualifying event, intensive CR programs (including named programs), virtual CR as an alternative to facility‑based CR, and non‑cardiac indications (e.g., SARS‑CoV‑2) as investigational due to insufficient evidence.

Definitions

Angina pectoris - definition

DefinitionANGINA PECTORIS: oppressive pain or pressure in the chest caused by inadequate blood flow and oxygenation to heart muscle.

Clinical contextOften indicates myocardial ischemia and is listed as a qualifying diagnosis for outpatient cardiac rehabilitation in this policy.

Angioplasty - definition

DefinitionANGIOPLASTY: an endovascular procedure that reopens narrowed blood vessels and restores forward blood flow.

Typical indicationPerformed to treat obstructive coronary artery disease (listed among qualifying procedures for cardiac rehabilitation).

Coronary artery bypass surgery - definition

Policy Summary

PayerCapital Bluecross

PolicyCardiac Rehabilitation in the Outpatient Setting

Policy CodePolicy MP 8.005

Change TypeRetiredcoding and coverage updates

Effective DateRETIRED 9/1/2025

Next Review Date

Key ActionLimit outpatient cardiac rehabilitation to 3 sessions per week for up to 12 weeks (36 sessions) and document qualifying diagnosis and required program components.

SourceLink

On This Page

G0422 — Intensive cardiac rehabilitation (moved to investigational).
G0423 — Intensive cardiac rehabilitation (moved to investigational).

Denial Risk

Coding‑related denial risk

Policy and coding changes (for example the movement of G0422/G0423 to investigational) can lead to claim denials if billed with codes that no longer align to the policy. Review historical billing practices and update billing systems to reflect current covered/ investigational code status to avoid denials.

Audit claims for G0422/G0423 and related codes to prevent inappropriate payment or denial.
Notify billing staff of coding updates and adjust internal claim edits or front‑end validation rules.

Documentation Required

Pre‑ and post‑program evaluation

A comprehensive evaluation may be performed prior to initiation of cardiac rehabilitation to determine an appropriate exercise program. This may include a medical exam and an electrocardiogram stress test; an additional stress test may be performed at program completion. Document pre‑ and post‑program evaluations in the medical record.

Document a comprehensive pre‑program evaluation (medical exam, risk assessment).
Document any ECG stress test performed before initiation and any stress testing at completion of the program.

Documentation Required

Required coding documentation

When submitting claims, include the specific procedure and diagnosis codes that support medical necessity. The policy's covered code lists (procedure and ICD‑10 diagnosis codes) must be present on the claim and in the medical record to substantiate coverage.

Include the appropriate CPT/HCPCS code(s) (eg, 93798 and associated S/HCPCS codes) and a qualifying ICD‑10 diagnosis from the policy's list.
Ensure the medical record documents the qualifying cardiac event or diagnosis that matches the billed diagnosis code.

Documentation Required

Documentation implications from policy edits

Policy edits have removed language and updated coding; for example, the phrase 'recommended by a cardiologist' was deleted and G‑codes were moved to investigational. Update clinical documentation templates and billing rules to reflect these changes so documentation and billed codes remain consistent with policy.

Remove any template or workflow requirement that references deleted language (eg, 'recommended by a cardiologist') unless separately required by contract.
Update coding tables and payer-facing billing guides to reflect moved/removed codes and new ICD‑10 additions.

Billing Rule

Concurrent PT/OT

Physical and/or occupational therapy provided concurrently with cardiac rehabilitation is not considered medically necessary unless it is for a diagnosis unrelated to the cardiac rehabilitation indication. Do not bill PT/OT in conjunction with cardiac rehabilitation for the same cardiac diagnosis.

Concurrent PT/OT with cardiac rehabilitation is not covered when billed for the same cardiac diagnosis.
If PT/OT is required for an unrelated diagnosis, document the unrelated diagnosis and medical necessity separately.

Note

No step therapy requirements explicitly stated

No step therapy requirements are specified in this section of the policy. There are no explicit step‑therapy or prior treatment sequencing rules described for outpatient cardiac rehabilitation within this policy section.

No step therapy requirements stated in this policy section.

DefinitionCORONARY ARTERY BYPASS SURGERY: surgical establishment of a shunt that permits blood to travel from the aorta or internal mammary artery to a branch of the coronary artery at a point past an obstruction.

RelevanceIdentified as a qualifying procedure for outpatient cardiac rehabilitation under the policy.

Heart failure - definition

DefinitionHEART FAILURE: the inability of the heart to circulate blood effectively enough to meet the body's metabolic needs.

Policy relevanceCompensated heart failure is listed as a qualifying indication for outpatient cardiac rehabilitation in the policy criteria.

Myocardial infarction - definition

DefinitionMYOCARDIAL INFARCTION: the death of previously living heart muscle as a result of coronary artery occlusion.

Timing thresholdAcute myocardial infarction within the preceding 12 months is a qualifying condition for outpatient cardiac rehabilitation per the policy.

Intensive cardiac rehabilitation - definition and policy stance

DefinitionIntensive cardiac rehabilitation: a programmatic, often lifestyle‑intensive variant of cardiac rehabilitation (examples include Pritikin, Ornish‑type programs).

Policy designationIn this policy intensive cardiac rehabilitation programs (e.g., Ornish, Pritikin, Benson‑Henry) are identified as investigational and not covered when billed using intensive CR codes (G0422, G0423).

ExamplesOrnish and Pritikin programs cited as examples of intensive cardiac rehabilitation.

Virtual/home‑based cardiac rehabilitation - definition

DefinitionVirtual/home‑based cardiac rehabilitation: cardiac rehabilitation services delivered at home or via virtual/telehealth modalities.

Policy notePolicy text documents evidence and references for virtual/home‑based cardiac rehabilitation and records that virtual CR was later added as medically necessary in policy history.

Intensive Cardiac Rehabilitation (ICR) - definition and coverage note

DefinitionIntensive Cardiac Rehabilitation (ICR): programs described in CMS NCDs and decision memos (examples: Ornish, Pritikin, Benson‑Henry Institute).

Coverage implicationCMS decision memos for ICR programs are referenced; within this policy ICR programs are specifically discussed and certain ICR codes (G0422, G0423) are designated investigational/not covered.