CurrentmhnPolicy CP.MP.176

Outpatient Cardiac Rehabilitation

Medical necessity guidelines for initiation and continuation of phase II outpatient cardiac rehabilitation and stance on phase III/IV and intensive cardiac rehabilitation programs for members of health plans affiliated with Centene Corporation.

Policy Summary

Payermhn

PolicyOutpatient Cardiac Rehabilitation

Policy CodePolicy CP.MP.176

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization when requesting up to 36 phase II outpatient cardiac rehabilitation visits (CPT 93798) over a period up to nine months.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≤36maximum visits approved for phase II outpatient cardiac rehabilitation

≤9 monthsmaximum period for the approved visits

93798supported CPT code

93797, G0422, G0423, S9472codes excluded from coverage

A53775CMS article referenced

Coverage Criteria — Cardiac Rehabilitation

Policy Summary

Payermhn

PolicyOutpatient Cardiac Rehabilitation

Policy CodePolicy CP.MP.176

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization when requesting up to 36 phase II outpatient cardiac rehabilitation visits (CPT 93798) over a period up to nine months.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Initial Therapy (Phase II) - Covered when ALL of the following are met

Covered when ALL of the following are met

Indications

Indication list: Any one of: Stable angina pectoris within last 12 months; Percutaneous coronary intervention within last 12 months; Myocardial infarction within last 12 months; Coronary artery bypass graft within last 12 months; Coronary artery disease within last six months; NYHA Class II, III, or IV and on a stable medication regimen; Heart or heart-lung transplantation within last six months or within six months of newly gained ability to participate; Cardiac valve surgery within last six months; Peripheral artery disease within last 12 months; History of sustained ventricular tachycardia or fibrillation or survivors of sudden cardiac death; Surgical septal myectomy via thoracotomy within last 12 months

Therapy program requirements: Program must include physician-prescribed exercise during each session and electrocardiogram monitoringboth required

Both items in I.B must be present

Utilization limits: Request is for ≤ 36 visits over a period of ≤ nine months≤ 36 visits; ≤ 9 months

Requests beyond this will be reviewed by a medical director

Contraindications absent

Contraindications list: Any of: 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 (eg active infection, uncontrolled diabetes, end-stage cancer, unstable psychological issues); Severe orthopedic conditions prohibiting exercise; Active endocarditis; Acute aortic dissection

Continuation Therapy (Phase II) - Covered when ALL of the following are met

Covered when ALL of the following are met

Progressive therapy program: Physician-prescribed exercise during each session and electrocardiogram monitoringboth required

Same monitoring and prescription as initial therapy

Partial progress

Progress components: 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 programall three present

Utilization limits: Request is for ≤ 36 visits, including those initially approved; requests for additional visits will be reviewed by a medical director

Phase III/IV programs - Not Medically Necessary

Phase III/IV stance: Phase III or IV cardiac rehabilitation programs are not medically necessary as they are primarily educational or training programsNA

Coverage stance: not medically necessary

Intensive Cardiac Rehabilitation (ICR) - Informational / Stance

ICR stance: There is not sufficient evidence that intensive cardiac rehabilitation (ICR) programs achieve superior outcomes compared to conventional cardiac rehabilitation programsNA

Policy references CMS definition of ICR and peer-reviewed literature requirement for demonstrating outcomes

Phase III and Phase IV cardiac rehabilitation programs are considered not medically necessary because they are primarily educational or training programs rather than medically supervised therapeutic rehabilitation. This policy stance applies to programs described as Phase III or Phase IV in the source guidance and is consistent with the plan's coverage determination that such programs do not meet medical necessity criteria.

Coverage determinations are governed by the member's specific coverage documents and are subject to the plan's terms, conditions, exclusions and limitations. When state Medicaid provisions conflict with this clinical policy, the applicable state Medicaid provisions take precedence. This policy is a guide to medical necessity and does not guarantee payment; providers should review the member's evidence of coverage, certificate of coverage, or contract for definitive benefit limits.

Phase III and Phase IV cardiac rehabilitation programs are explicitly listed as not medically necessary by the plan because they are primarily educational or training programs. Requests for services identified as Phase III or IV should be denied as not meeting medical necessity under this policy.

Provider Actions, Authorization & Documentation

Prior Authorization

Prior Authorization for Phase II (>36 visits / extended duration)

Prior authorization is required for Phase II outpatient cardiac rehabilitation when requests exceed plan-specified visit limits or when local plan policy requires review. Verify member eligibility and obtain authorization before initiating services to avoid claim denials or retroactive denials.

Affected codes: CPT 93798 (Phase II, per session); 93797 not supporting coverage criteria
Authorization threshold: requests > 36 visits or duration > 9 months
Check payer-specific prior authorization portals and timeframes

Note

Check CMS coverage and frequency rules

Confirm and follow CMS local coverage and frequency guidance for cardiac rehabilitation programs. CMS local policy may define maximum allowed visits, program definitions, and billing rules; align requests with those rules to ensure coverage.

CMS limits typically referenced in coverage determinations and frequency guidance
If CMS guidance differs from state Medicaid policy, follow the applicable program rules for the member

Denial Risk

Exceeding allowed visits / Phase III/IV programs

Exceeding the allowed visits (for example, more than 36 sessions or beyond nine months) or enrolling members in Phase III/IV maintenance programs that are not medically necessary increases administrative denial risk. Obtain prior authorization and provide documentation justifying medical necessity for additional visits or for enrollment in later-phase programs.

Phase III/IV maintenance programs are commonly considered non-covered or require separate review
Submit clinical justification when requesting visits beyond plan limits (progress notes, functional status, continued objective improvement)

Documentation Required

Session-level documentation and progress

Maintain comprehensive session-level documentation and align records with regulatory and payer requirements. Documentation should support medical necessity, ongoing functional improvement, and physician-prescribed exercise for each session.

Document physician order, session date/time, supervised exercise plan, ECG monitoring data, vitals, patient response, and progress toward goals
Retain records that justify number of visits requested and any extensions

Documentation Required

Documentation and regulatory alignment

Ensure documentation and administrative processes reflect regulatory alignment and plan disclaimers. Follow state Medicaid provisions where they supersede plan policy, and adhere to any provider notification requirements tied to policy effective dates.

When state Medicaid rules conflict with this clinical policy, state rules take precedence — consult state Medicaid manual
Maintain copies of prior authorizations, medical records, and any communications for audit and appeals

Denial Risk

Administrative coverage and denial risk

Administrative coverage limits and incomplete or missing documentation are common reasons for claim denials. Proactively confirm coverage details, submission requirements, and include all supporting clinical information to reduce denial risk.

Common denial risks: lack of physician order, missing ECG monitoring documentation, requests beyond 36 visits without justification
If denied, follow plan-specific appeals process and supply requested medical records promptly

Definitions

inv-20: Cardiac rehabilitation — definition

TermCardiac rehabilitation (CR)

DefinitionCoordinated, multifaceted interventions designed to optimize a cardiac patient's physical, psychological, and social functioning and to stabilize, slow, or reverse progression of atherosclerotic processes, thereby reducing morbidity and mortality.

Core componentsMedical evaluation; supervised exercise training with ECG monitoring; risk factor reduction; nutrition and psychosocial support.

inv-21: Intensive cardiac rehabilitation (ICR) — definition

TermIntensive cardiac rehabilitation (ICR)

DefinitionA physician-supervised program that furnishes cardiac rehabilitation services more frequently and often in a more rigorous manner than conventional programs.

Qualification criteria (per CMS)ICR programs must demonstrate in peer-reviewed literature at least one outcome: positively affect progression of coronary heart disease; reduce need for coronary bypass surgery; or reduce need for percutaneous coronary interventions.

Examples of programsPritikin, Ornish, Benson-Henry Institute programs (licensed commercial programs with exercise, nutrition counseling, stress management, group support and extended follow-up).

inv-22: Intensive Cardiac Rehabilitation — literature reference term

Literature termIntensive Cardiac Rehabilitation

ContextTerm used in literature to describe higher-intensity rehabilitation programs studied in high‑risk cardiovascular patients (see Świątkiewicz et al., Nutrients 2021).

Representative referencesŚwiątkiewicz I et al., Nutrients. 2021; CMS transmittal and other lifestyle modification program studies cited in policy bibliography.

OpenPayer

Outpatient Cardiac Rehabilitation

Coverage Criteria — Cardiac Rehabilitation

Coding — CPT and Billing References

Provider Actions, Authorization & Documentation

Background — Cardiac Rehabilitation Overview

Definitions

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