OUTPATIENT PULMONARY REHABILITATION
Customize your policy alerts
Sign up for Capital Bluecross Policy MP 8.008 alerts
Get alerted when Policy MP 8.008 changes without checking for updates manually.
Monitor payer policy activity
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 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).
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.
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.
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.
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.
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
| G0305 | Pulmonary rehabilitation, including exercise (eg, treadmill, stationary bicycle, calisthenics), one hour, per session |
| 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 |
| 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 |
Provider Actions
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.
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.
Use specified procedure codes
Report appropriate HCPCS/CPT procedure codes when services meet medical necessity. Use the listed covered codes when billing; do not bill investigational/not covered codes.
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
Policy retired effective 10/1/2025.
Retirement Review (document last reviewed prior to retirement).
Administrative update: ICD-10 code J44.89 added as part of new code update effective 10/1/2023.
Administrative update: Procedure codes 94625 and 94626 added and G0424 removed (effective 1/1/2022).
FEP variation added / FEP product variation referenced; consensus review noted with no changes to policy statements.
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.