RetiredCapital BluecrossPolicy MP 8.008

OUTPATIENT PULMONARY REHABILITATION

Defines Capital BlueCross medical policy MP 8.008 for outpatient pulmonary rehabilitation (PR), specifying situations considered medically necessary, investigational/not covered, candidate requirements, coding, and product/benefit variations. Applies to outpatient clinic-based PR programs; notes product-specific benefit limits govern actual coverage.

Policy Summary

PayerCapital Bluecross

PolicyOUTPATIENT PULMONARY REHABILITATION

Policy CodePolicy MP 8.008

Change TypeRetirement (10/1/2025)earlier administrative coding updates

Effective Date

Next Review Date

Key ActionDocument that patient meets medically necessary criteria (moderate-to-very severe chronic pulmonary disease, medically stable, comprehensive outpatient PR program including exercise conditioning) and, if preoperative, that patient is an appropriate candidate for LVRS or lung transplantation.

SourceLink

POLICY UPDATE CHANGES

Policy retired effective 10/1/2025.

ICD-10 code J44.89 was added as part of a code update effective 10/1/2023.

Procedure codes 94625 and 94626 were added and G0424 removed, effective 1/1/2022.

FEP product variation referenced and FEP variation added (no change to policy statements).

3Medically necessary indications (single course)

3Investigational / not covered categories

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Coverage Summary

Defines Capital BlueCross medical policy MP 8.008 for outpatient pulmonary rehabilitation (PR), specifying situations considered medically necessary and investigational, candidate requirements, coding guidance, and product/benefit variations; applies to outpatient clinic-based PR programs and notes product-specific benefit limits govern actual coverage.

Coverage stance: mixed. Policy status = RETIRED; retirement effective date: RETIRED 10/1/2025.

Medical-Necessity Criteria

Medically Necessary (Single Course, Outpatient)

A single course of outpatient pulmonary rehabilitation may be considered medically necessary when ALL of the following are met:

ALL of the following

Patient has chronic pulmonary disease with moderate-to-very severe disease (e.g., COPD and other chronic lung diseases such as interstitial lung disease, bronchiectasis, cystic fibrosis, asthma, pulmonary arterial hypertension, lung cancer, lung transplantation candidates).
Program is outpatient and comprehensive (team assessment, patient training, psychosocial intervention, exercise training, and follow-up) with exercise conditioning as an essential component.
Exercise conditioning is essential; education without exercise does not improve outcomes in COPD.
Patient is medically stable and not limited by another serious or unstable medical condition.

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Medically Necessary (Preoperative Conditioning)

A single course of outpatient PR may be considered medically necessary as a preoperative conditioning component when ALL of the following are met:

ALL of the following

Patient is an appropriate candidate for lung volume reduction surgery (LVRS) or lung transplantation.
Program is outpatient and intended as preoperative conditioning.

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Medically Necessary (Post-Transplant)

Pulmonary rehabilitation programs are considered medically necessary when ALL of the following are met:

ALL of the following

Patient has undergone lung transplantation.
Program is outpatient and comprehensive.

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Investigational / Not Medically Necessary

Pulmonary rehabilitation is considered investigational (insufficient evidence) in the following situations:

ANY of the following

Multiple courses of outpatient pulmonary rehabilitation (maintenance therapy, repeat courses for failure to respond, or diminished response to initial program).
Home-based pulmonary rehabilitation programs.
Pulmonary rehabilitation following other types of lung surgery (including but not limited to LVRS and surgical resection of lung cancer) — insufficient evidence for general conclusion.
Pulmonary rehabilitation in all other situations not specified as medically necessary.

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Candidate Contraindications

Individuals should be medically stable and not limited by other conditions; specific contraindications include ANY of the following:

ANY of the following

Severe psychiatric disturbance (e.g., dementia, organic brain syndrome).
Significant or unstable medical conditions (e.g., congestive heart failure, acute cor pulmonale, substance abuse, significant liver dysfunction, metastatic cancer, disabling stroke).

Coding

Investigational; therefore, not covered (Procedure Codes)HCPCSNot Covered

G0305

Pulmonary rehabilitation, including exercise (eg, treadmill, stationary bicycle, calisthenics), one hour, per session

Covered when medically necessary (Procedure Codes)HCPCSCovered

94625	Pulmonary rehabilitation; exercise training
94626	Pulmonary rehabilitation; respiratory muscle training
G0237	Therapeutic procedure to improve respiratory function, per session
G0238	Pulmonary rehabilitation; exercise only, per session
G0239	Pulmonary rehabilitation; education only, per session
G0302	Pulmonary rehabilitation, non-face-to-face or other PR related
G0303	Pulmonary rehabilitation, other code variant
G0304	Pulmonary rehabilitation, other code variant
S9473	Pulmonary rehabilitation program, non-physician provider, per session

Relevant ICD-10-CM Diagnosis Codes (listed in policy)ICD-10

D38.1	Neoplasm of uncertain behavior of trachea, bronchus, and lung
D86.0	Sarcoidosis of lung
D86.1	Sarcoidosis of lymph nodes
D86.2	Sarcoidosis of lung with sarcoidosis of lymph nodes
D86.9	Sarcoidosis, unspecified
E84.0	Cystic fibrosis with pulmonary manifestations
E84.9	Cystic fibrosis, unspecified
I27.0	Primary pulmonary hypertension
I27.20	Pulmonary hypertension, unspecified
I27.23	Pulmonary hypertension due to lung diseases and hypoxia

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Provider Actions

Documentation Required

Medical necessity documentation

Document that the patient meets medically necessary criteria: moderate-to-very severe chronic pulmonary disease; patient is medically stable and not limited by another serious or unstable medical condition; care is delivered in a comprehensive outpatient PR program that includes team assessment, therapeutic interventions, psychosocial support, follow-up, and exercise conditioning as an essential component. If the PR is for preoperative conditioning, document that the patient is an appropriate candidate for lung volume reduction surgery (LVRS) or lung transplantation.

Prior Authorization

Benefit & preauthorization check

Verify the member's specific health benefit plan for whether outpatient pulmonary rehabilitation is a covered benefit, any applicable benefit limits, and whether preauthorization is required. Note that the medical policy indicates medical necessity criteria and coding guidance but does not by itself guarantee that services will be covered under the member's benefit plan.

Background & Evidence Summary

Outpatient pulmonary rehabilitation (PR) is a multidisciplinary program including team assessment, therapeutic interventions (exercise training, education, behavior change), psychosocial support, and follow-up. Program components generally include physician and multidisciplinary team assessment, individual training (breathing retraining, bronchial hygiene, medication and nutrition instruction), psychosocial interventions, exercise training (strengthening and conditioning such as treadmill walking, cycle training, inspiratory muscle training, stair climbing, and arm exercises), and follow-up.

Exercise conditioning is an essential component of PR; education or disease-management instruction without exercise conditioning does not improve outcomes in COPD. Although most research has focused on COPD, PR has been applied to other chronic lung diseases (e.g., interstitial lung disease, bronchiectasis, cystic fibrosis, asthma, pulmonary arterial hypertension, lung cancer) and in preoperative and post-transplant or post–lung surgery contexts.

Sufficient evidence: A single course of outpatient PR improves functional ability and quality of life in individuals with moderate-to-severe COPD and is sufficient to determine meaningful improvement in net health outcome.

Insufficient evidence: Home-based PR, multiple courses/maintenance PR, PR for many non-COPD surgical or other indications (including many post-surgical settings other than transplant), and PR surrounding other types of lung surgery lack sufficient evidence to determine health outcomes or benefits.

Pulmonary rehabilitation (PR): A comprehensive outpatient program including team assessment, therapeutic interventions (exercise training, education, behavior change), psychosocial support, and follow-up with exercise conditioning as an essential component.

Medicare Determinations

Name	Number	Effective Year	Type
National Coverage Determination for Pulmonary Rehabilitation Services	240.8	2008	NCD

Revision History

10/01/2025retirementLatest

Policy retired effective 10/1/2025.

04/25/2025retirement_review

Retirement Review (document last reviewed prior to retirement).

08/30/2023administrative_update