CurrentUnitedHealthcarePolicy BIP138.R

Cardiac Rehabilitation Services - Outpatient

Defines coverage for outpatient cardiac rehabilitation services provided by authorized clinicians in physician offices, hospitals, or alternate outpatient facilities for UnitedHealthcare members.

Policy Summary

PayerUnitedHealthcare

PolicyCardiac Rehabilitation Services - Outpatient

Policy CodePolicy BIP138.R

Change TypeRoutine reviewno change

Effective DateJan 1, 2026

Next Review Date

Key ActionProvide outpatient cardiac rehabilitation only when performed by an authorized provider within scope of practice and in eligible outpatient settings; follow member Evidence of Coverage/Schedule of Benefits and any prior authorization requirements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1policy number

Jan 1, 2026effective date

No changesummary of changes

3covered sections

Coverage Criteria for Outpatient Cardiac Rehabilitation

Covered Outpatient Cardiac Rehabilitation

Covered when ALL of the following are met:

Provider and setting: Services are performed by a physician, a licensed therapy provider, or other provider licensed, certified, or otherwise authorized under state law to perform the service, and within the provider's scope of practice

Performed in a physician's office or on an outpatient basis at a hospital or alternate facility

Cardiac Rehabilitation services that do not meet the covered criteria are not covered.

Provider Requirements, Prior Authorization, and Billing Notes

Prior Authorization

Coverage and Prior Authorization Note

Outpatient cardiac rehabilitation services are covered when performed by a physician, a licensed therapy provider, or other provider who is licensed, certified, or otherwise authorized under state law to perform the service, within the provider's scope of practice, and provided in a physician's office or on an outpatient basis at a hospital or alternate facility. All services must be medically necessary and conform to the member's Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member's EOC/SOB, the EOC/SOB governs.

Policy Summary

PayerUnitedHealthcare

PolicyCardiac Rehabilitation Services - Outpatient

Policy CodePolicy BIP138.R

Change TypeRoutine reviewno change

Effective DateJan 1, 2026

Next Review Date

SourceLink

On This Page

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Prior authorization: Follow the member's plan requirements for prior authorization where applicable; verify authorization requirements with the member's EOC/SOB.
Provider eligibility: Service must be performed by a physician, licensed therapy provider, or other provider authorized under state law and within scope of practice.
Place of service: Covered only when provided in a physician's office or on an outpatient basis at a hospital or alternate outpatient facility.
Home services: Rehabilitative services provided in a member's home by a home health agency are billed under the home health benefit; home services by other providers follow outpatient rehabilitation benefit rules.
Documentation: Maintain medical records demonstrating medical necessity and conformance with EOC/SOB to support claims.
Billing rule: Cardiac rehabilitation services that do not meet coverage criteria are not covered and may be denied per the member's plan.

Denial Risk

Denial Risk for Nonconforming Services

Cardiac rehabilitation services that do not meet the coverage criteria described in this policy and the member's EOC/SOB are not covered and may be denied. Verify that services, provider credentials, place of service, and medical necessity align with the member's plan before billing.

Denial risk: Services not meeting criteria — e.g., performed by an unlicensed/unqualified provider, outside scope of practice, in non-covered setting, or lacking documentation of medical necessity — may be denied.
Action: Prior to providing or billing services, confirm coverage specifics in the member's EOC/SOB and obtain any required authorizations.

Documentation Required

Medical Necessity and Plan Provisions

All services must be medically necessary and conform to the member's Evidence of Coverage/Schedule of Benefits; if a discrepancy exists between this policy and the member's EOC/SOB, the member's EOC/SOB provisions will govern. Providers should verify benefit coverage, prior authorization, and any plan-specific limitations before delivering services.

Medical necessity: Document clinical indications that justify cardiac rehabilitation per the member's plan criteria.
Plan provisions: Check member-specific EOC/SOB for coverage limitations, maximum sessions, and other exclusions.
Discrepancy resolution: When policy conflicts with EOC/SOB, follow the EOC/SOB.

Billing Rule

Provider-action / Billing-rule Highlight

Provider-action / billing-rule highlights: ensure appropriate provider credentials, place of service, prior authorizations, and documentation are in place; bill under the correct benefit (outpatient rehabilitation or home health) depending on the setting and provider type.

Bill outpatient cardiac rehabilitation under outpatient rehabilitation services when provided in an outpatient facility or physician office.
If services are provided in the member's home by a home health agency, bill under the home health benefit.
Verify and obtain any required prior authorization per the member's EOC/SOB before initiating services.
Retain clinical documentation to support medical necessity and coverage decisions.

Background

Cardiac rehabilitation is a medically supervised program designed to improve cardiovascular health after events such as heart attack, heart failure, angioplasty, or heart surgery. It typically includes exercise counseling and training, education for heart-healthy living, and counseling to reduce stress to support recovery and reduce future cardiovascular risk.

Definitions

inv-08: Cardiac Rehabilitation — definition and short description.

TermCardiac Rehabilitation

DefinitionA medically supervised program designed to improve cardiovascular health after heart attack, heart failure, angioplasty, or heart surgery.

Core componentsExercise counseling and training; education for heart-healthy living; counseling to reduce stress.

Exercise counseling and trainingTeaches safe, effective physical activity to get the heart and cardiovascular system working and promote heart health.

Education for heart-healthy livingInstruction on managing risk factors and self-care (for example, smoking cessation and heart-healthy nutrition).

Counseling to reduce stressHelps identify and address everyday sources of stress that negatively affect heart health.