Cigna Cardiac Rehab Phase II Coverage Update | OpenPayer

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Cigna Cardiac Rehab Phase II Coverage Update | OpenPayer

Coverage Criteria for Phase II Outpatient Cardiac Rehabilitation

Medically necessary indications for Phase II outpatient CR

Covered when ANY of the following qualifying events are present and the customer's benefit plan provides coverage:

Qualifying Events: acute myocardial infarction (MI)

Phase II CPT codes 93797/93798

Qualifying Events: coronary artery bypass grafting (CABG)

Phase II CPT codes 93797/93798

Qualifying Events: percutaneous coronary vessel remodeling (percutaneous coronary intervention/PCI)

Phase II CPT codes 93797/93798

Qualifying Events: valve replacement or repair

Phase II CPT codes 93797/93798

Qualifying Events: coronary artery disease (CAD) with chronic stable angina refractory to pharmacotherapy and interfering with activities of daily living or functional abilities

Phase II CPT codes 93797/93798

Qualifying Events: heart failure refractory to pharmacotherapy and interfering with activities of daily living or functional abilities

Phase II CPT codes 93797/93798

Qualifying Events: following surgical septal myectomy via thoracotomy

Phase II CPT codes 93797/93798

Qualifying Events: heart transplantation or heart-lung transplantation

Phase II CPT codes 93797/93798

Qualifying Events: major pulmonary surgery, great vessel surgery, or MAZE arrhythmia surgery

Phase II CPT codes 93797/93798

Qualifying Events: placement of a ventricular assist device

Phase II CPT codes 93797/93798

Qualifying Events: sustained ventricular tachycardia or fibrillation

Phase II CPT codes 93797/93798

Qualifying Events: survivors of sudden cardiac arrest

Phase II CPT codes 93797/93798

Programs considered not medically necessary

The following program types are considered educational/training and not medically necessary:

Not Medically Necessary Programs: Phase III or IV cardiac rehabilitation programs

Considered educational/training in nature and not medically necessary

Not Medically Necessary Programs: Intensive cardiac rehabilitation programs (HCPCS codes G0422, G0423) including examples such as the Pritikin Program, Ornish Program for Reversing Heart Disease, Benson-Henry Institute Cardiac Wellness Program

Considered educational/training in nature and not medically necessary

General Cardiac Rehabilitation Coverage Criteria

Covered when ALL of the following are met

Qualifying diagnosis or event: Patient is eligible based on qualifying diagnoses/events (e.g., acute MI, chronic stable angina, CABG, PCI, cardiac valve surgery, cardiac transplantation, or heart failure with reduced ejection fraction) occurring within the prior 12 months when specified by performance measureswithin past 12 months when specified

ACC/AHA performance measures; a 'full dose' of 36 sessions associated with improved outcomes

Program type and risk stratification: A comprehensive outpatient Phase II CR program is prescribed; for low-risk patients a home-based CR program may be substituted for a supervised center-based program per guideline recommendationslow-risk for home substitution

2011 AHA/ACC guideline: substitution for low-risk patients (Class I)

Assessment and monitoring:

Updated policy statement

Summary of material changes from the annual review:

Policy-level changes: Revised policy statement for cardiac rehabilitation; removed the term 'center-based' from the policy statement and removed prior noncoverage language for virtual/remote home-based and hybrid cardiac rehabilitation

Annual Review dated 5/15/2025 (and prior change 6/15/2024)

Claims for services that are not submitted with covered diagnosis and/or procedure codes specified by this Coverage Policy will be denied as not covered. When billing, providers must use the most appropriate and current codes as of the date of submission; reimbursement is not permitted for services billed for conditions or diagnoses that are not covered under this policy. Note that a customer's specific benefit plan document may contain exclusions that supersede this Coverage Policy.

The following HCPCS codes for Intensive Cardiac Rehabilitation are listed as Not Medically Necessary under this policy and will trigger denial if billed: G0422, G0423. Additionally, the non-physician per diem code S9472 is listed as not medically necessary in the policy's coding table.

The policy was revised at annual review to remove prior noncoverage language distinguishing program delivery models. Specifically, the policy statement was updated to remove the term 'center-based' and prior noncoverage statements for virtual/remote home-based and hybrid cardiac rehabilitation were removed; no explicit exclusions for those models appear in the provided excerpt.

Phase II outpatient cardiac rehabilitation delivered in a physician-directed outpatient setting (CPT codes 93797, 93798) is considered medically necessary when the patient meets qualifying event criteria listed in the policy (for example, recent acute MI, CABG, PCI, valve surgery, heart transplantation, placement of a ventricular assist device, sustained ventricular arrhythmia, or survivor of sudden cardiac arrest). For low-risk patients, guideline-supported substitution of home-based or hybrid CR for supervised outpatient CR is acknowledged where appropriate.

Per the policy, intensive cardiac rehabilitation codes G0422 and G0423, and the non-physician per diem code S9472, are considered Not Medically Necessary and therefore are not covered. Providers should not submit claims for these codes expecting reimbursement under this policy.

Within the excerpt provided there are no additional specific clinical conditions listed beyond those already described that are labeled 'not medically necessary.' The policy identifies Phase III/IV programs and intensive cardiac rehabilitation models as educational/training in nature and lists the intensive program codes as not medically necessary; beyond these items, no other explicit not medically necessary conditions are included in this fragment.

Coding, Timing, and Session Details

Covered CPT Codes (Phase II CR when medically necessary)CPTCovered

93797	Physician services for outpatient cardiac rehabilitation; with continuous ECG monitoring (per encounter) — listed in policy as Phase II CR CPT
93798	Physician services for outpatient cardiac rehabilitation; without continuous ECG monitoring (per encounter) — listed in policy as Phase II CR CPT

Not medically necessary HCPCS CodesHCPCSNot Covered

G0422	Intensive cardiac rehabilitation; with exercise (per session) — listed as educational/training and not medically necessary
G0423	Intensive cardiac rehabilitation; without exercise (per session) — listed as educational/training and not medically necessary

Considered Medically Necessary when criteria metCPTCovered

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).

Considered Not Medically NecessaryHCPCSNot Covered

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

No codes listed in this excerptmixed

No codes listed

Timing for initiation — Phase II CR

Typical initiation timingProgram typically initiated within 1–3 weeks after hospital discharge and generally administered within six months

Recommended pre-enrollment testingSymptom-limited exercise tolerance/stress test recommended before entry when available

Alternate baseline assessmentsWhen graded exercise testing unavailable, Talk Test or 6-minute walk test may be used

Session frequency and duration

Typical session scheduleMost Phase II programs: three sessions per week for 12 weeks

CMS session limits

Provider Actions, Prior Authorization, and Billing Rules

Prior Authorization

Prior Authorization for Phase II Cardiac Rehabilitation

Prior authorization is required for outpatient Phase II cardiac rehabilitation (CPT 93797, 93798) when the member’s plan provides coverage and the clinical criteria in this policy are met. Verify plan benefits and obtain prior authorization before initiating Phase II CR to avoid claim denials or delays.

Affected codes: 93797, 93798
Prior authorization required when plan coverage exists and medical-necessity criteria are met

Prior Authorization

Prior Authorization Requirement — Verify per plan

No explicit universal prior-authorization exception is specified in this policy. Providers must confirm whether the member’s specific benefit plan requires prior authorization and follow payer-specific utilization review processes.

Check the member’s benefit plan document for plan-specific prior authorization rules
Medical directors may exercise clinical discretion for individual determinations

Background and Scope

Cardiac rehabilitation (CR) is a coordinated, multifaceted intervention that includes supervised exercise training, education, and risk-factor modification to improve physical, psychological, and social functioning and reduce cardiovascular morbidity and mortality. Phase II refers to physician-directed outpatient CR typically initiated within 1–3 weeks after hospital discharge and generally administered within six months; programs commonly provide structured exercise, counseling, and risk-factor management to support recovery after qualifying cardiac events.

Definitions and Program Models

Phase II Cardiac Rehabilitation (definition)

DefinitionMultifaceted, physician-directed outpatient rehabilitation from hospital discharge to ~2–12 weeks later, including prescribed exercise, risk-factor management, education, and counseling

Supervision and monitoringIncludes both ECG-monitored and non-ECG-monitored sessions; exercise intensity individualized by testing

Program goalsAims to improve conditioning, reduce symptoms, stabilize/reverse atherosclerotic process, and improve psychosocial/vocational status

Phases I–IV of Cardiac Rehabilitation

Phase IInpatient rehabilitation during hospitalization for an acute cardiac event; focuses on early mobilization and activity progression

Phase IIOutpatient, medically supervised rehabilitation (physician-directed) following discharge

Policy Revision History

2025-05-15annual_reviewLatest

Revised policy statement for cardiac rehabilitation (annual review).

2024-06-15policy_update

Removed 'center-based' from policy statement and removed prior noncoverage language for virtual/remote home-based and hybrid cardiac rehabilitation.