Effective Date:

a)    This policy will apply to all services performed on or after the above Revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

Cardiac rehabilitation is covered under the medical benefit.

Cardiac rehabilitation programs are used to allow patients to regain strength and capacity after certain cardiac events. These programs are conducted under physician supervision and consist of patient specific exercise programs using continuous EKG monitoring.

Cardiac rehabilitation is eligible for coverage only when it is conducted under physician supervision with continuous EKG monitoring as defined by:

• The program is provided in either the outpatient department of a hospital or in a physician directed clinic;
• The physician is on the premises available to perform medical duties at all times the facility is open and each patient is under the care of a hospital or clinic physician;
• The facility has available for immediate use all the necessary cardio-pulmonary emergency diagnostic and therapeutic lifesaving equipment accepted by the medical community as medically necessary, e.g., oxygen, cardiopulmonary resuscitation equipment, or defibrillator;
• The program is staffed by personnel necessary to conduct the program safely and effectively, who are trained in both basic and advanced life support techniques and in exercise therapy for coronary disease. Services of non-physician personnel must be furnished under the direct supervision of a physician. Direct supervision means that a physician must be in the exercise program area. It does not mean the physician must physically be present in the exercise room itself but must be immediately available and accessible for an emergency at all times;
• The program provides patient education in areas of nutrition, smoking, controlling stress, and any other life style habits that affect coronary disease.

Cardiac rehabilitation is considered medically necessary when it is prescribed by a physician for members within 12 months after any of the following:

1. Acute myocardial infarction; or
2. Coronary artery bypass grafting (CABG); or
3. Percutaneous coronary vessel remodeling (i.e., angioplasty, Atherectomy, stenting); or
4. Valve replacement or repair; or
5. Heart transplantation; or
6. Major pulmonary surgery, great vessel surgery, or MAZE arrhythmia surgery; or
7. Sustained ventricular tachycardia or fibrillation, or survivors of sudden cardiac death; or
8. Class III or IV congestive heart failure unresponsive to medical therapy; or
9. AHA Class III or IV after significant cardiomyopathy or  
10. Chronic stable angina pectoris unresponsive to medical therapy which prevents the member from functioning optimally to meet domestic or occupational needs.

Codes Used In This BI:

93797             Cardiac Rehab (without physician monitoring/supervision) – not covered

93798             Cardiac Rehab/Monitor

• Cardiac rehabilitation is not eligible for coverage for members who have an exercise test of greater than 9 metabolic equivalents (METS).
• Cardiac rehabilitation without continuous EKG monitoring (93797) is not covered.
• Physical and Occupational Therapy services are not covered as a routine part of a Cardiac Rehabilitation Program.
• Patient Education is not covered as a separately identifiable service when rendered as part of a Cardiac Rehabilitation Program.
• Room and Board furnished to patients or family members by some free-standing facilities is not covered.

1.     Arkansas BlueCross BlueShield Coverage Policy Manual, Cardiac Rehabilitation at: http://www.arkansasbluecross.com/members/report.aspx?policyNumber=1997151

1. American College of Cardiology (ACC). Cardiovascular Rehabilitation. ACC Position Statement. Bethesda, MD: ACC; 1985: 1-6. Available at: http://www.acc.org/clinical/position/72539.pdf
2. Pasquali SK, Alexander KP, Peterson ED. Cardiac rehabilitation in the elderly. Am Heart J. 2001; 142(5):748-755.
3. Ades PA. Cardiac rehabilitation and secondary prevention of coronary heart disease. N Engl J Med. 2001; 345(12):892-902.
4. Balady GJ, Ades PA, Comoss P, et al. Core components of cardiac rehabilitation/secondary prevention programs: A statement for healthcare professionals from the American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation Writing Group. Circulation. 2000; 102(9):1069-1073.
5. Stone JA, Cyr C, Friesen M, et al. Canadian guidelines for cardiac rehabilitation and atherosclerotic heart disease prevention: A summary. Can J Cardiol. 2001; 17 Suppl B: 3B-30B.
6. Jolliffe JA, Rees K, Taylor RS, et al. Exercise-based rehabilitation for coronary heart disease (Cochrane Review). In: The Cochrane Library, Issue 4, 2003. Chichester, UK: John Wiley & Sons, Ltd.
7. Rees K, Taylor RS, Ebrahim S. Exercise based rehabilitation for heart failure (Protocol for a Cochrane Review). In: The Cochrane Library, Issue 4, 2003. Chichester, UK: John Wiley & Sons, Ltd.
8. Stewart KJ, Badenhop D, Brubaker PH, et al. Cardiac rehabilitation following percutaneous revascularization, heart transplant, heart valve surgery, and for chronic heart failure. Chest. 2003; 123(6):2104-2111.
9. Giannuzzi P, Saner H, Bjornstad H, et al. Secondary prevention through cardiac rehabilitation: Position paper of the Working Group on Cardiac Rehabilitation and Exercise Physiology of the European Society of Cardiology. Eur Heart J. 2003; 24(13):1273-1278.
10. National Institute for Clinical Excellence (NICE), North of England Evidence-based Guidelines Development Project. Prophylaxis for patients who have experienced a myocardial infarction: Drug treatment, cardiac rehabilitation and dietary manipulation - guideline. London, UK: NICE; 2001.
11. Institute for Clinical Systems Improvement (ICSI). Cardiac rehabilitation. Bloomington, MN: ICSI; 2002.
12. Brown A, Noorani H, Taylor R, et al. A clinical and economic review of exercise-based cardiac rehabilitation programs for coronary artery disease. Technology Overview No. 11. Ottawa, ON: Canadian Coordinating Office for Health Technology Assessment (CCOHTA); August 2003.
13. Gordon NF, Gulanick M, Costa F, et al. Physical activity and exercise recommendations for stroke survivors: An American Heart Association scientific statement from the Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention; the Council on Cardiovascular Nursing; the Council on Nutrition, Physical Activity, and Metabolism; and the Stroke Council. Circulation. 2004; 109(16):2031-2041.
14. Centers for Medicare and Medicaid Services (CMS). Cardiac rehabilitation programs. National Coverage Determination. Coverage Issues Manual Sec. 20.10. Baltimore, MD: CMS; effective August 1, 1989. Available at: http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=20.10&ncd_version=2&basket=ncd%3A20%2E10%3A2%3ACardiac+Rehabilitation+Programs
15. Herridge ML, Stimler CE, Southard DR, et al. Depression screening in cardiac rehabilitation: AACVPR Task Force Report. J Cardiopulm Rehabil. 2005; 25(1):11-13.

17. Aetna Clinical Policy bulletins; Cardiac rehabilitation available at: http://www.aetna.com/cpb/data/CPBA0021.html

Addendum:

1.     Effective 07/01/2017 Changed eligible time period from 6 weeks to 12 months after diagnosis or event.  Also clarified pre-authorization requirement and exclusion of coverage without continuous EKG monitoring.

This policy applies to all health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD,  EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.