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.

Pulmonary rehabilitation is a structured outpatient program, directed by physicians and therapists, designed to improve tolerance to activities of daily living. Pulmonary rehabilitation is normally covered under the limitation of the Physical Therapy / Occupational Therapy benefit – and the number of visits is limited by the limitations of this benefit. Additional treatments are not covered unless specifically pre-authorized by QualChoice.

Coverage for pulmonary rehabilitation does not include rental/purchase of exercise equipment or memberships in health/exercise clubs.

Entry into a medically supervised outpatient pulmonary rehabilitation program is considered medically necessary when all of the following criteria are met:

1. Member has chronic pulmonary disease (including asthma (J45.50-J45.51), emphysema (J43.0-J43.9), chronic bronchitis (J41.0-J42), chronic airflow obstruction (J44.0-J44.9), cystic fibrosis (E84.0), alpha-1 antitrypsin deficiency (E88.01), pneumoconiosis (J60-J66.8), asbestosis (J61), radiation pneumonitis (J70.0), pulmonary fibrosis (J84.10), pulmonary alveolar proteinases (J84.01), pulmonary hemosiderosis (J84.03), fibro sing alveolitis(J84.112)); and
2. Member has a reduction of exercise tolerance which restricts the ability to perform activities of daily living (ADL) and/or work; and
3. Member does not have a recent history of smoking or has quit smoking for at least 6 months; and
4. Member has a moderate to moderately severe functional pulmonary disability as evidenced by either of the following:
   • Pulmonary function tests showing that either the FEV1, FVC, FEV1/FVC, or Dlco is less than 60 % of that predicted; or
   • A maximal pulmonary exercise stress test under optimal bronchodilator treatment which demonstrates a respiratory limitation to exercise with a maximal oxygen uptake (VO2max) equal to or less than 20 ml/kg/min, or about 5 metabolic equivalents (METS); and
5. Member does not have any concomitant medical condition that would otherwise imminently contribute to deterioration of pulmonary status or undermine the expected benefits of the program (e.g., symptomatic coronary artery disease, congestive heart failure, myocardial infarction within the last 6 months, dysrhythmia, active joint disease, claudication, malignancy).

A typical course of pulmonary rehabilitation extends for up to 6 weeks or 36 hours of therapy.

Codes Used in this BI:

94625 Physician or other qualified health care prof svcs for outpt pulmonary rehab; w/o continuous oximetry monitoring (per session)

94626 Physician or other qualified health care prof svcs for outpt pulmonary rehab; w/continuous oximetry monitoring (per session)

S9473 Pulmonary rehabilitation program, nonphysician provider, per diem

Pulmonary rehabilitation is not considered medically necessary in persons who have very severe pulmonary impairment as evidenced by dyspnea at rest, difficulty in conversation (one-word answers), inability to work, cessation of most of all usual activities making them housebound and often limiting them to bed or chair with dependency upon assistance from others for most ADL. According to available guidelines, persons with very severe pulmonary impairment are not appropriate candidates for pulmonary rehabilitation.

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