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    v1.0.28
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyUniversity Health Alliance Ornish Cardiac Rehab Co…
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    CurrentUniversity Health Alliance (HSA)Policy MPP-0123-170321

    Intensive Cardiac Rehabilitation (Dr. Dean Ornish Program) — Reimbursement and Medical Necessity

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    This policy governs UHA reimbursement and medical necessity criteria for intensive cardiac rehabilitation delivered through the Dr. Dean Ornish Program and applies to University Health Alliance members and participating providers.

    Policy Summary
    PayerUniversity Health Alliance (HSA)
    PolicyIntensive Cardiac Rehabilitation (Dr. Dean Ornish Program) — Reimbursement and Medical Necessity
    Policy CodePolicy MPP-0123-170321
    Change TypeNo material changes
    Effective DateMar 1, 2022
    Last ReviewMar 1, 2022
    Next Review DateN/A
    Key ActionSubmit prior authorization for Ornish program participation through the Ornish Reversal Program delivery site; claims may include up to 4 units of G0422 or G0423 per date of service.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    4one-hour sessions per day in the program
    12 monthseligibility window after key cardiac events
    ≤35%LVEF threshold for CHF eligibility
    II-IV

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Required NYHA symptom class

    Medical Necessity & Eligibility

    Medical and administrative eligibility criteria

    Intensive cardiac rehabilitation through the Ornish Program is considered medically necessary when ALL of the following clinical and administrative eligibility criteria are met:

    Event-based indications (ANY one of)

    • Within a 12-month window after an acute myocardial infarction.
    • Within a 12-month window after coronary artery bypass surgery.
    • Within a 12-month window after heart valve repair or replacement.
    • Within a 12-month window after percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting.
    • Within a 12-month window after heart or heart–lung transplant.
    Member has a current diagnosis of stable angina pectoris unresponsive to medical therapy that prevents optimal functioning (particularly with modifiable coronary risk factors or poor exercise tolerance).

    ALL of the following

    • Left ventricular ejection fraction (LVEF) ≤ 35%.
    • New York Heart Association (NYHA) functional class II–IV symptoms despite being on optimal heart failure therapy for at least 6 weeks.
    • Stable CHF defined as no recent (≤ 6 weeks) or planned (≤ 6 months) major cardiovascular hospitalizations or procedures.

    ALL of the following

    • Prospective participants should be motivated to complete the program and make necessary lifestyle changes.
    • Preliminary screening by an accredited Ornish Reversal Program delivery site to confirm motivation and eligibility prior to acceptance.
    • Participants must be nonsmokers or have quit smoking at least 2 months before starting the program.
    • Acceptance into the program is at the sole discretion of the Ornish Reversal Program delivery site; acceptance does not guarantee coverage.

    ALL of the following

    • Referral must be initiated by the health care provider overseeing the patient’s eligible condition.
    • Delivery site must submit prior authorization for participation as required by UHA administrative guidelines.
    • Participants must continue to work with their referring provider; the Ornish Reversal Program nurse/case manager will coordinate care adjustments with the referring provider.
    Administrative compliance with UHA requirements (e.g., prior authorization, certified delivery site billing) is required for coverage.

    Administrative details (prior authorization submission method, billing/site responsibilities, and per‑day unit limits) are specified in Administrative Guidelines and Coding sections.

    Billing Codes and Units

    Intensive cardiac rehabilitation session codesHCPCSCovered
    G0422Intensive cardiac rehabilitation; with or without continuous ECG monitoring with exercise, per session
    G0423Intensive cardiac rehabilitation; with or without ECG monitoring without exercise, per session
    Units per day
    Allowed units per date of serviceUp to 4 units (one per one-hour session) of G0422 or G0423 per date of service
    Session lengthOne-hour sessions (4 sessions per program day)
    Applicable HCPCS codesG0422, G0423
    Billing instructionClaims should report a maximum of 4 units of G0422 or G0423 per date of service

    Prior Authorization, Referral & Billing Responsibilities

    Prior Authorization

    Prior authorization and billing rules for Ornish Program

    Prior authorization is required for participation in the Ornish program and must be submitted by the Ornish Reversal Program; no prior authorization is required to refer members for initial evaluation. Claims should include up to 4 units of G0422 or G0423 per date of service, and baseline and end-of-program measurements and reports are required for claims payment. To request prior authorization, submit via UHA's website at uhahealth.com/page/prior-authorizationforms.

    • Prior authorization for participation must be submitted by the Ornish Reversal Program (not the referring physician).
    • No prior authorization required for referral for initial evaluation.
    • Limit claims to 4 units of G0422 or G0423 per date of service (program has 4 one-hour sessions per day).
    • Baseline and end-of-program measurements and reports are required for claims payment.
    • Prior authorization requests submitted via UHA website: uhahealth.com/page/prior-authorizationforms.

    Key Definitions

    Stable CHF (brief)
    Definition (compact)Stable congestive heart failure (CHF): CHF in persons who have not had recent (≤6 weeks) or planned (≤6 months) major cardiovascular hospitalizations or procedures
    LVEF requirementLeft ventricular ejection fraction (LVEF) ≤35%
    NYHA classNew York Heart Association (NYHA) class II–IV symptoms
    Duration of optimal therapySymptoms despite optimal heart failure therapy for at least 6 weeks
    Stable CHF (detailed)
    Detailed definitionStable CHF: documented CHF in persons who have not had recent (≤6 weeks) or planned (≤6 months) major cardiovascular hospitalizations or procedures
    Policy Summary
    PayerUniversity Health Alliance (HSA)
    PolicyIntensive Cardiac Rehabilitation (Dr. Dean Ornish Program) — Reimbursement and Medical Necessity
    Policy CodePolicy MPP-0123-170321
    Change TypeNo material changes
    Effective DateMar 1, 2022
    Last ReviewMar 1, 2022
    Next Review DateN/A
    Key ActionSubmit prior authorization for Ornish program participation through the Ornish Reversal Program delivery site; claims may include up to 4 units of G0422 or G0423 per date of service.
    SourceLink
    On This Page
    Medical Necessity & EligibilityBilling Codes and UnitsPrior Authorization, Referral & Billing ResponsibilitiesKey Definitions
    Billing Rule

    Referral and billing responsibilities

    The referring physician does not bill for Ornish Reversal Program services; all Ornish program billing is done by the certified delivery site. The referring physician should bill UHA for any required testing and for office visits needed to manage the chronic disease or adjust the care plan as the patient progresses.

    • Certified Ornish delivery site is responsible for billing all Ornish program services.
    • Referring physician should bill for required testing for program participation and outcomes measurement.
    • Referring physician should bill for office visits to manage chronic disease or cardiac risk factors and to adjust the care plan during program participation.
    Clinical thresholds
    LVEF of 35% or less and NYHA class II–IV symptoms
    Therapy requirementSymptoms persist despite being on optimal heart failure therapy for at least 6 weeks
    Temporal context for program eligibilityWithin a 12-month window of documented stable CHF for Ornish Program eligibility