CurrentCentenePolicy CP.MP.176

Outpatient Cardiac Rehabilitation

Medical necessity guidelines for initiation and continuation of phase II outpatient cardiac rehabilitation (conventional and intensive) for Centene-affiliated health plans; describes covered indications, program requirements, visit limits, and contraindications.

Policy Summary

PayerCentene

PolicyOutpatient Cardiac Rehabilitation

Policy CodePolicy CP.MP.176

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization documenting indication, physician-prescribed exercise each session, ECG monitoring, and that the request is for ≤36 visits over ≤9 months.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≤36max approved visits (≤9 mo)

12 molookback window (MI/PCI/CABG)

6 molookback window (CAB/tx/valve)

NYHA II-IVHF eligibility

41+references

Coverage Criteria for Phase II Outpatient Cardiac Rehabilitation

Policy Summary

PayerCentene

PolicyOutpatient Cardiac Rehabilitation

Policy CodePolicy CP.MP.176

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization documenting indication, physician-prescribed exercise each session, ECG monitoring, and that the request is for ≤36 visits over ≤9 months.

SourceLink

On This Page

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Initiation of phase II outpatient cardiac rehabilitation

Covered when ALL of the following are met

Indications: One of the following indications is present: (1) Stable angina pectoris within last 12 months; (2) Percutaneous coronary intervention within last 12 months; (3) Myocardial infarction within last 12 months; (4) Coronary artery bypass graft (CABG) within last 12 months; (5) Coronary artery disease within last six months; (6) New York Heart Association (NYHA) Class II, III, or IV and on a stable medication regimen; (7) Heart or heart-lung transplantation within last six months, or within six months of newly gained ability to participate in rehabilitation regimen; (8) Cardiac valve surgery within last six months; (9) Peripheral artery disease within last 12 months; (10) History of sustained ventricular tachycardia or fibrillation, or survivors of sudden cardiac death; (11) Surgical septal myectomy via thoracotomy within last 12 months.

Supported by policy indications list

Therapy program elements: All of the following: (1) Physician-prescribed exercise during each session; (2) Electrocardiogram monitoring.

Required program elements

Visit limit: Request is for ≤ 36 visits over a period of ≤ nine months.≤36 visits; ≤9 months

Visit frequency/duration limit

Contraindications absent: None of the following contraindications are present: unstable angina; orthostatic blood pressure drop >20 mmHg with symptoms; symptomatic severe aortic stenosis (aortic valve area <1.0 cm2); uncontrolled atrial or ventricular arrhythmias with hemodynamic compromise; decompensated heart failure; active pericarditis or myocarditis; active pulmonary embolism, pulmonary infarction or deep vein thrombosis; acute thrombophlebitis; acute systemic illness or fever; unstable or life‑threatening noncardiovascular conditions (e.g., active infection, uncontrolled diabetes, end‑stage cancer, unstable psychological issues); severe orthopedic conditions that prohibit exercise; active endocarditis; acute aortic dissection.

Contraindication list must be checked

Continuation of phase II outpatient cardiac rehabilitation

Covered when ALL of the following are met

Progressive therapy program: All of the following: (1) Physician-prescribed exercise during each session; (2) Electrocardiogram monitoring.

Same program elements as initiation

Partial progress: All of the following: (1) Reduction in intensity and frequency of symptoms or findings; (2) Improvement in function and reduction in limitations; (3) Documented patient adherence to home exercise program.

Documented partial progress required for continuation

Visit limit and review: Request is for ≤ 36 visits, including those initially approved. Requests for additional visits will be reviewed by a medical director.≤36 visits total; additional require medical director review

Continuation visit cap and escalation process

Phase III/IV and Intensive Cardiac Rehabilitation stance

Phase III/IV: Phase III or IV cardiac rehab programs are not medically necessary as they are primarily educational or training programs.

Not covered: phase III/IV

Intensive cardiac rehabilitation: There is not sufficient evidence that intensive cardiac rehabilitation programs achieve superior outcomes compared to conventional cardiac rehabilitation programs.

ICR not shown superior — policy notes insufficiency of evidence

Phase III and IV cardiac rehabilitation programs are considered not medically necessary under this policy because they are primarily educational or training programs rather than supervised, ECG‑monitored therapeutic rehabilitation. Codes listed as not supporting coverage criteria include 93797, G0422, G0423, and S9472 and use of these codes may trigger denial of coverage.

Coverage determinations are subject to the member’s individual coverage documents and plan terms. The policy provides medical necessity guidance only; actual benefits, exclusions, limitations and administrative rules are governed by the member’s evidence of coverage, certificate of coverage, policy or contract and any applicable Health Plan administrative procedures.

Phase III and IV cardiac rehabilitation programs are explicitly designated as not medically necessary by this policy because they are primarily educational or training programs and do not meet the supervised therapeutic criteria required for coverage.

Coding and Visit Limits

Codes that support coverage criteriaCPTCovered

93798

Physician or other qualified health care professional services for outpatient cardiac rehabilitation; with continuous ECG monitoring (per session)

Codes that do not support coverage criteriamixedNot Covered

93797	Physician or other qualified health care professional services for outpatient cardiac rehabilitation; without continuous ECG monitoring (per session)
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.
S9472	Cardiac rehabilitation program, non-physician provider, per diem

inv-09: Visit limit — ≤ 36 visits over a period of ≤ nine months

Visit limitRequests must be for ≤ 36 visits total

Time windowVisits must occur within a period of ≤ nine months

ApplicabilityLimit applies to initiation and continuation requests (≤36 visits total); requests beyond this require medical director review

Provider Actions, Authorization and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for phase II outpatient cardiac rehabilitation. Phase II outpatient CR is medically necessary only when all policy indications, program elements, and visit limits are met.

Requests for Phase II outpatient cardiac rehabilitation should document indication, physician-prescribed exercise each session, ECG monitoring, and program elements per policy.
For Medicare members, follow applicable Medicare NCDs, LCDs, and Coverage Articles prior to applying policy criteria.

Documentation Required

Required Clinical Documentation

Required clinical documentation must support the indication within specified timeframes, physician-prescribed exercise during each session, ECG monitoring, program elements, and patient progress as applicable.

Documentation must demonstrate the qualifying indication occurred within the timeframe listed in policy (e.g., MI, PCI, CABG within 12 months; CAD within six months; transplant or valve surgery within six months).
For continuation requests, provide evidence of partial progress toward treatment goals, adherence to home exercise program, and ongoing physician-prescribed exercise and ECG monitoring.

Billing Rule

Visit Limits and Review

Visit limits are enforced. Requests for more than the covered number of visits require additional review.

Initial and continuation requests combined are limited to ≤ 36 visits over a period of ≤ nine months.
Requests exceeding ≤36 visits or a period > nine months may be denied; additional visits will be reviewed by a medical director.

Step Therapy

No Step Therapy Required

The policy does not impose any step therapy requirements for cardiac rehabilitation.

No step therapy or prior conservative-treatment trials are specified as prerequisites for coverage of Phase II outpatient cardiac rehabilitation.

Billing Rule

Non-supported CPT/HCPCS Codes

Certain CPT/HCPCS codes do not support coverage criteria and may trigger denial if billed for services intended to meet this policy.

Codes that do not support coverage criteria: 93797 (without continuous ECG monitoring), G0422, G0423 (intensive cardiac rehabilitation codes), and S9472 (cardiac rehabilitation program, non-physician provider, per diem).
Use appropriate, supported CPT/HCPCS codes that align with the documented services and continuous ECG monitoring requirements; billing unsupported codes may result in denial.

Denial Risk

Denial Risk Due to Coverage Document/Exclusion

Coverage decisions are subject to the terms and exclusions of the member's coverage documents; this policy is a guide to medical necessity and not a guarantee of payment.

Decisions may be denied based on the member's evidence of coverage, certificate of coverage, policy exclusions, limitations, or other contractual provisions.
The Health Plan makes no representation or guarantee of payment; authorization does not supersede contract terms or exclusions.

Note

Medicare Documentation/Coding Alignment

Medicare-specific documentation and coding requirements must be reviewed and followed for Medicare members to ensure consistency with Medicare coverage determinations.

Review applicable Medicare National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Medicare Coverage Articles (for example, CMS Local Coverage Article A53775) prior to applying this policy for Medicare members.
Follow CMS billing and coding guidance referenced by the policy when submitting claims for Medicare enrollees.

Note

Provider Action — Medical Director Review

Provider action placeholder: ensure all documentation and billing align with policy and payer contract; consult medical director for requests beyond limits or unclear cases.

If clinical circumstances warrant more than the allowed visits or duration, submit detailed justification for medical director review.
Contact the plan prior authorization or medical director as needed for exceptions or clarifications.

Definitions

inv-20: Phase II outpatient cardiac rehabilitation — ECG-monitored, supervised exercise programs

Core definitionElectrocardiogram‑monitored, supervised exercise programs tailored to patient needs

Frequency & durationUsually 2–3 times weekly for 8–12+ weeks

Program elementsIncludes physician‑prescribed exercise during each session and comprehensive secondary prevention services (risk‑factor reduction, nutrition, psychosocial support)

Monitoring requirementContinuous ECG monitoring during sessions is required for covered phase II services

inv-21: Intensive cardiac rehabilitation (ICR) — Physician-supervised programs

ICR descriptionPhysician‑supervised programs that furnish cardiac rehabilitation services more frequently and often more rigorously than conventional CR

Qualification requirementTo qualify, ICR programs must demonstrate in peer‑reviewed literature at least one favorable outcome (affect CHD progression, reduce need for CABG, or reduce need for PCI) per CMS

ExamplesEstablished programs include Pritikin, Ornish, and Benson‑Henry Institute programs

inv-22: outpatient cardiac rehabilitation — Definition / summary of cardiac rehabilitation

DefinitionCoordinated, multifaceted interventions to optimize physical, psychological, and social functioning and stabilize or slow atherosclerotic disease

ComponentsMedical evaluation, exercise training, risk‑factor reduction/secondary prevention, nutrition counseling, psychosocial support, and education

Clinical benefitsEvidence shows reduced mortality, myocardial infarction, and readmissions; improved exercise capacity and quality of life

OpenPayer

Outpatient Cardiac Rehabilitation

Coverage Criteria for Phase II Outpatient Cardiac Rehabilitation

Coding and Visit Limits

Provider Actions, Authorization and Documentation

Definitions

Background