CurrentKaiser PermanentePolicy N/A

Clinical Review Criteria — Cardiac Rehabilitation

Defines medical necessity, documentation, and coding guidance for outpatient and intensive cardiac rehabilitation services for Kaiser Foundation Health Plan of Washington members, including Medicare and non‑Medicare populations.

Policy Summary

PayerKaiser Permanente

PolicyClinical Review Criteria — Cardiac Rehabilitation

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionIf requesting this service, submit the last 6 months of cardiology notes to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 codesApplicable CPT/HCPCS codes listed

MCG KP-0358Non‑Medicare medical necessity source

CMS NCD 20.10.1Medicare coverage reference

6 months notesRequested documentation

Coverage and Medical Necessity Criteria

Medical necessity sources and linkage

Covered when ALL of the following are met according to the referenced source documents

Medicare members: Medical necessity must follow CMS Coverage Manuals (Medicare Claims Processing Manual Chapter 32, Section 140) and National Coverage Determination 20.10.1 (Cardiac Rehabilitation Programs for Chronic Heart Failure). Local Coverage Article LCA A54070 (retired) remains relevant for determining medical necessity and should be used for review when applicable.refer to CMS NCD 20.10.1 and Medicare Claims Processing Manual Chapter 32 Section 140

See referenced Medicare sources (NCD and retired LCA A54070) for specific inclusion/exclusion criteria and documentation requirements

Non-Medicare members: Medical necessity determinations use the Cardiac Rehabilitation (KP-0358) MCG guideline for clinical criteria.refer to MCG KP-0358

MCG is proprietary; providers may request the specific MCG criteria used for an individual utilization management decision by contacting Kaiser Permanente Clinical Review staff.

Policy Summary

PayerKaiser Permanente

PolicyClinical Review Criteria — Cardiac Rehabilitation

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionIf requesting this service, submit the last 6 months of cardiology notes to support medical necessity.

SourceLink

On This Page

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Coding and Documentation Requirements

Considered medically necessary when criteria metmixedCovered

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)
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, nonphysician provider, per diem

Documentation timeframe

Required documentation timeframeLast 6 months of cardiology notes

Purpose of documentationSupport medical necessity determination for cardiac rehabilitation services

When to submitInclude with prior authorization or service request to expedite review

Scope of notesCardiology outpatient notes covering the clinical course, diagnosis, and functional status within the 6‑month window

Provider Actionables and Authorization

Prior Authorization

Authorization for listed codes

The following CPT/HCPCS codes are considered medically necessary when the policy criteria are met. Verify prior authorization requirements by plan type using the Pre-authorization Code Check.

93797
93798
G0422
G0423
S9472

Denial Risk

Services must meet medical necessity

Services must meet medical necessity as outlined in the applicable Medicare and Kaiser Permanente criteria. For Medicare members, follow CMS Coverage Manuals and NCD/LCA guidance (see LCA A54070 for determining medical necessity). For non‑Medicare members, Kaiser Permanente uses the Cardiac Rehabilitation (KP-0358) MCG criteria.

Documentation Required

Required documentation to support medical necessity

When requesting review, include documentation to support medical necessity. At minimum, provide the last 6 months of cardiology notes. Additional clinical records may be requested to complete review.

Last 6 months of cardiology notes

Denial Risk

Provider denial risk

Failure to meet the stated medical necessity criteria may result in claim denial. Providers should confirm applicable coverage rules (Medicare vs Non‑Medicare) and obtain necessary authorizations before rendering services.

Background

Cardiac rehabilitation (CR) is a multidisciplinary program intended to restore functional capacity and reduce cardiovascular risk after acute cardiac events or in chronic cardiovascular disease. Core elements include baseline assessment, individualized exercise training, risk-factor management, nutritional counseling, psychological support, and education to help patients resume optimal functioning and reduce disease progression.

CR programs are typically delivered in outpatient center-based settings (hospitals, gyms, or community centers) but may also be offered as structured home-based cardiac rehabilitation alternatives that include defined objectives, monitoring, and follow-up (for example, scheduled visits, telephone contacts, mailed materials, or patient self-monitoring). The policy recognizes home-based CR as an access-focused option, while also noting that comparative evidence versus center-based programs was evaluated in the MTAC review.

Definitions

Cardiac rehabilitation — definition and key elements

DefinitionCardiac rehabilitation (CR) is a multifactorial, comprehensive intervention coordinating interventions to optimize physical, psychological, and social conditions so patients with chronic or post‑acute cardiovascular disease may preserve or resume optimal functioning and reduce disease progression.

Core componentsBaseline patient assessment, nutritional counseling, risk factor management (weight, blood pressure, lipids, diabetes, smoking), psychological interventions, physical activity counseling, and exercise training.

Primary goalsMobilize the patient, optimize drug therapy, implement secondary prevention measures, educate for behavior modification, treat psychological disturbances, and improve reintegration into work and society.

Program modelMultidisciplinary, professional integrated approach applying preventive care and long‑term cardiac risk reduction strategies.

Home‑based cardiac rehabilitation — definition and components

DefinitionHome‑based cardiac rehabilitation: a structured alternative to center‑based CR with clear objectives and interventions delivered at home to improve access and participation.

Monitoring methodsMay include remote monitoring, self‑monitoring diaries, scheduled telephone calls, visits, letters, or other staff contact to track progress and safety.

Follow‑up componentsRegular follow‑up via visits or telephone contacts to review exercise, symptoms, adherence, and risk‑factor control.

Intended benefitIncrease participation among patients who face barriers to center‑based programs (e.g., accessibility, dislike of groups, work/domestic commitments).