Pulmonary Rehabilitation
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This policy governs Moda Health coverage and prior authorization requirements for medically supervised outpatient pulmonary rehabilitation. It applies to members with qualifying chronic pulmonary disease, selected preoperative or postoperative lung transplant or lung reduction pneumoplasty needs, and documented functional impairment who meet the stated medical necessity criteria.
The 2026 annual review added CPT codes 94625 and 94626 and replaced deleted code G0424.
Medical Necessity and Coverage Criteria
Initial outpatient pulmonary rehabilitation
Medically supervised outpatient pulmonary rehabilitation is covered, subject to applicable plan limitations, when the patient has a qualifying chronic pulmonary disease and ALL of the following criteria are met:
Qualifying chronic pulmonary disease
- Qualifying diagnosis: The patient has at least one listed chronic pulmonary disease or another documented chronic lung disease or condition affecting pulmonary function.
Listed conditions include alpha-1-antitrypsin deficiency, asbestosis, asthma, chronic airflow obstruction, chronic bronchitis, COPD, cystic fibrosis, emphysema, fibrosing alveolitis, pneumoconiosis, pulmonary alveolar proteinosis, pulmonary fibrosis, pulmonary hemosiderosis, radiation pneumonitis, ALS, ankylosing spondylitis, bronchopulmonary dysplasia, Guillain-Barré syndrome or other infective polyneuritis, muscular dystrophy, myasthenia gravis, diaphragmatic paralysis, sarcoidosis, and scoliosis.
Clinical and functional requirements
- The patient is referred by a board-certified pulmonologist or primary care physician who is actively involved in the patient's care.
- The patient has dyspnea at rest or with exertion.
- The patient has had a reduction in exercise tolerance within the past 30 days that restricts the ability to perform activities of daily living.
- Symptoms persist despite appropriate medical management.
Objective moderate to severe functional pulmonary impairment
- A maximal pulmonary exercise stress test under optimal bronchodilatory treatment demonstrates respiratory limitation to exercise.VO2max ≤20 ml/kg/min, or approximately 5 METS
- Pulmonary function testing shows that at least one of the following is less than 60% of predicted: FEV1, FVC, FEV1/FVC ratio, or DLCO.
Participation and safety requirements
- The patient is physically able, motivated, and willing to participate in the pulmonary rehabilitation program and is expected to be a candidate for self-care after the program.
- The patient has no other medical or psychological limitation that prevents participation.
Examples include symptomatic coronary artery disease, congestive heart failure, myocardial infarction within the last 6 months, dysrhythmia, active joint disease, claudication, or malignancy.
Lung transplant or reduction pneumoplasty
Pulmonary rehabilitation is covered when the patient meets this alternative qualifying pathway:
This is an alternative qualifying pathway to the chronic pulmonary disease criteria.
Duration and plan limitations
Coverage is subject to applicable plan limitations for short-term rehabilitation therapies:
Coverage may be subject to applicable plan limitations for short-term rehabilitation therapies.
Pulmonary rehabilitation requested for indications other than those listed in this policy is considered experimental and investigational because clinical effectiveness for those indications has not been established.
Preoperative pulmonary rehabilitation for persons undergoing surgery for lung cancer is considered experimental and investigational because the effectiveness of this approach has not been established.
Very severe pulmonary impairment is characterized by dyspnea at rest, difficulty conversing beyond one-word answers, inability to work, cessation of most usual activities, being housebound or frequently confined to a bed or chair, and dependence on others for most activities of daily living.
Pulmonary rehabilitation is not medically necessary for persons with very severe pulmonary impairment. According to available guidelines, these individuals are not appropriate candidates for pulmonary rehabilitation because of their substantial functional dependence and limited ability to participate.
Covered Services and Applicable Codes
| G0237 | Therapeutic procedures to increase strength or endurance of respiratory muscles, face-to-face, one-on-one, each 15 minutes (includes monitoring). |
| G0238 | Therapeutic procedures to increase respiratory function, other than described by G0237, one-on-one, face-to-face, per 15 minutes (includes monitoring). |
| G0239 | Therapeutic procedures to improve respiratory function or increase strength or endurance of respiratory muscles, 2 or more individuals (includes monitoring). |
| 94625 | Physician or other qualified healthcare professional services for outpatient pulmonary rehabilitation; without continuous oximetry monitoring, per session. |
| 94626 | Physician or other qualified healthcare professional services for outpatient pulmonary rehabilitation; with continuous oximetry monitoring, per session. |
| S9473 | Pulmonary rehabilitation program, non-physician provider, per diem. |
| 94669 | Mechanical chest wall oscillation to facilitate lung function, per session. |
| D86.0 | Sarcoidosis of lung. |
| E84.0 | Cystic fibrosis with pulmonary manifestations. |
| J41.0-J41.8 | Simple and mucopurulent chronic bronchitis. |
| J43.0-J43.9 | Emphysema. |
| J44.0-J44.9 | Other chronic obstructive pulmonary disease. |
| J47.0-J47.9 | Bronchiectasis. |
| J60 | Coalworker's pneumoconiosis. |
| J62.0-J62.8 | Pneumoconiosis due to dust containing silica. |
| J63.0-J63.6 | Pneumoconiosis due to other inorganic dusts. |
| J64 | Unspecified pneumoconiosis. |
Prior Authorization and Documentation Requirements
Prior Authorization Submission Required
Prior authorization is required for pulmonary rehabilitation. Submit the documentation listed below with the request so Moda Health can evaluate medical necessity.
- The last six months of medical records from the ordering physician documenting the diagnosis and current medical management.
- Results of a recent pulmonary function test.
Medical Records Required
Submit the last six months of medical records from the ordering physician with the prior authorization request.
- Records must indicate the patient's diagnosis and current medical management.
Recent Pulmonary Function Testing Required
Include results of a recent pulmonary function test with the prior authorization request.
Medical Necessity Criteria
Documentation should establish that the patient meets the medical-necessity criteria for covered pulmonary rehabilitation.
- Referral by a board-certified pulmonologist or primary care physician actively involved in the patient's care.
- A qualifying chronic pulmonary disease or other documented chronic condition affecting pulmonary function, or preoperative/postoperative lung transplant or reduction pneumoplasty.
- Dyspnea at rest or with exertion.
- A reduction in exercise tolerance within the past 30 days that restricts activities of daily living.
- Symptoms persisting despite appropriate medical management and moderate-to-severe functional pulmonary impairment, as supported by qualifying exercise testing or pulmonary function testing.
Unlisted Indications
Requests for pulmonary rehabilitation for indications other than those listed in the policy may be denied as experimental and investigational because clinical effectiveness has not been established.
Preoperative Lung Cancer Surgery
Preoperative pulmonary rehabilitation for persons undergoing surgery for lung cancer is considered experimental and investigational and is not covered under this policy.
Very Severe Impairment
Pulmonary rehabilitation is not medically necessary for persons with very severe pulmonary impairment who are not appropriate candidates for the program.
- Examples include dyspnea at rest, difficulty conversing with one-word answers, inability to work, cessation of most usual activities with housebound status, limitation to bed or chair, or dependence on others for most activities of daily living.
Participation Requirements
Coverage is not supported unless the patient is physically able, motivated, and willing to participate in pulmonary rehabilitation and is expected to be a candidate for self-care after the program.
Contraindicating Comorbidity
Coverage is not supported when another medical or psychological limitation prevents participation in pulmonary rehabilitation.
- Examples include symptomatic coronary artery disease, congestive heart failure, myocardial infarction within the last six months, dysrhythmia, active joint disease, claudication, or malignancy.
Pulmonary Rehabilitation Overview
Pulmonary rehabilitation is a restorative and preventive multidisciplinary program for patients with chronic pulmonary disease. It combines exercise training, psychosocial support, education, and follow-up to improve quality of life and restore the highest possible functional capacity. The policy generally addresses medically supervised outpatient rehabilitation for patients with chronic pulmonary disease and demonstrable functional limitation.
Key Definition
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