BlueCross and BlueShield of Montana Medical Policy/Codes
Cardiac Rehabilitation (CR)
Chapter: Therapies
Current Effective Date: November 26, 2013
Original Effective Date: March 01, 1990
Publish Date: November 26, 2013
Revised Dates: October 15, 2003; September 14, 2005; October 1, 2010; August 13, 2012; October 24, 2013
Description

Cardiac rehabilitation (CR) refers to comprehensive medically supervised programs in the outpatient setting that aim to improve the function of patients with heart disease and prevent future cardiac events. National organizations have recently specified core components to be included in cardiac rehabilitation programs.

In 1995, the U.S. Public Health Service (USPHS) defined cardiac rehabilitation services as, in part, “comprehensive, long-term programs involving medical evaluation, prescribed exercise, cardiac risk factor modification, education, and counseling. These programs are designed to limit the physiologic and psychological effects of cardiac illness, reduce the risk for sudden death or reinfarction, control cardiac symptoms, stabilize or reverse the atherosclerotic process, and enhance the psychosocial and vocational status of selected patients.” This USPHS guideline recommends cardiac rehabilitation services for patients with coronary heart disease (CHD) and with heart failure, including those awaiting or following cardiac transplantation. (1) This definition remains current as of 2011.

A 2010 definition of cardiac rehabilitation by the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation is as follows: “Cardiac rehabilitation can be viewed as the clinical application of preventive care by means of a professional multi-disciplinary integrated approach for comprehensive risk reduction and global long-term care of cardiac patients.” (2)

A routine session consists of rehabilitation training sessions lasting 20–40 minutes and one or more of the following services:

  • Continuous electrocardiographic (ECG) monitoring during exercise;
  • EKG rhythm strip with interpretation and physician’s revision of exercise program; and
  • Physician follow-up to adjust medication or other treatment related to program.

Note:  This policy does not address programs considered“Intensive Cardiac Rehabilitation Programs,” such as the Dean Ornish Program for Reversing Heart Disease and the Pritikin Program.

Policy

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coverage

Outpatient cardiac rehabilitation (CR) programs may be considered medically necessary for patients with a history of one of the following conditions and/or procedures:

  • Acute myocardial infarction (MI) (heart attack);
  • Coronary artery bypass graft (CABG) surgery;
  • Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting;
  • Heart valve surgery;
  • Heart or heart-lung transplantation;
  • Current stable angina pectoris;
  • Compensated heart failure, or
  • Transmyocardial revascularization.

A cardiac rehabilitation (CR) exercise program may be considered medically necessary for three sessions per week up to a 12-week period (36 sessions). Programs are to start within 90 days of the cardiac event and to be completed within six months of the cardiac event.

A comprehensive evaluation may be considered medically necessary when performed prior to initiation of CR to evaluate the patient and determine an appropriate exercise program. In addition to a medical examination, an electrocardiogram (ECG) stress test may be performed. An additional stress test may be performed at the completion of the program.

Physical and /or occupational therapy are considered not medically necessary in conjunction with cardiac rehabilitation unless performed for an unrelated diagnosis.

Repeat participation in an outpatient cardiac rehabilitation program in the absence of another qualifying cardiac event is considered experimental, investigational and unproven.

Rationale

This policy was originally developed in 1990 and has been updated with searches of scientific literature through January 2013.  This section of the current policy has been substantially revised. The following is a summary of the key literature to date.

Many randomized controlled trials (RCTs) have been published comparing cardiac rehabilitation (CR) to usual care for patients with established heart disease, and several meta-analyses of RCTs have been performed. Two recent meta-analyses on cardiac rehabilitation were conducted by the Cochrane collaboration, one including patients with coronary heart disease (CHD) and the other focusing on patients with systolic heart failure.(3, 4) Both reviews addressed exercise-based cardiac rehabilitation programs (exercise-alone or as part of comprehensive program).

In 2011, Heran and colleagues identified 47 RCTs with 10,794 patients comparing cardiac rehabilitation to usual care in patients with CHD. (3) Seventeen of the studies used exercise-only interventions, and 29 used comprehensive rehabilitation (i.e., exercise plus psychosocial and/or educational interventions). The majority of studies (32 of 47, 68%) were conducted in Europe. Trial sample size ranged from 28 to 2,304. The median duration of rehabilitation interventions was 3 months, and there was a median follow-up duration of 24 months. The investigators reported that most studies had limited information available on methodologic quality. Due to the nature of the intervention, patients were not blinded to treatment group in any of the studies. Only 4 studies reported that there was blinded assessment of study outcomes. In a pooled analysis of data from 17 trials reporting all-cause mortality after at least 12 months of follow-up, cardiac rehabilitation resulted in a significantly lower mortality rate compared to usual care (relative risk [RR]: 0.87, 95% confidence interval [CI]: 0.75-0.99). Similarly, a pooled analysis of findings from 12 trials with at least 12 months follow-up found a significantly lower rate of cardiovascular mortality in the cardiac rehabilitation compared to the usual care group (RR: 0.74, 95% CI: 0.63-0.87). In sensitivity analyses of a priori defined variables, the investigators did not find a significant association between health outcomes and the type of cardiac rehabilitation (i.e., exercise-only versus comprehensive cardiac rehabilitation), length of the intervention or study publication date (i.e., published before 1995 or 1995 and later).

The 2010 Cochrane review by Davies and colleagues identified 19 trials with 3,647 heart failure patients; one large trial, HF-ACTION, contributed 2,331 (60%) patients. (4) The overall quality of the studies was judged poor; for example, only 3 studies adequately described their randomization process, and only 3 studies had blinded outcome assessment. A pooled analysis of the 13 studies reporting all-cause mortality with up to 12 months’ follow-up, did not find a statistically significant difference in mortality between groups (RR: 1.02, 95% CI: 0.70 to 1.51). Similarly, there was not a significant difference between groups in all-cause mortality in a pooled analysis of the 4 studies reporting more than 12 months’ follow-up (RR: 0.88, 95% CI: 0.73 to 1.07). No significant between-group differences were found for the other primary outcome variable, hospital admissions. For example, when findings from 5 studies reporting hospital admissions up to 12 months were pooled, the relative risk was 0.79 (95% CI: 0.58 to 1.07). The vast majority of the studies included in the Cochrane review, including the HF-ACTION trial, were exercise-only interventions; thus, conclusions cannot be drawn from this review regarding the impact of comprehensive cardiac rehabilitation programs on mortality or hospital admissions in patients with heart failure. The Cochrane review did not require that studies only include patients with compensated heart failure.

A 2011 meta-analysis by Lawler and colleagues addressed exercise-based cardiac rehabilitation programs for patients who had a recent myocardial infarction (MI). (5) To be included in the review, trials needed to include minimum intervention duration of 2 weeks and a minimum of 12 weeks of follow-up. Interventions could involve any form of exercise program, with or without other interventions. A total of 34 RCTs with 6,111 patients met the review’s inclusion criteria. In a pooled analysis of data from 18 trials, patients randomized to cardiac rehabilitation had a significantly lower risk of reinfarction than patients randomized to a control condition (odds ratio [OR]: 0.53, 95% CI: 0.38-0.76). There was also a lower risk of all-cause mortality (OR: 0.74, 95% CI: 0.58-0.95) and cardiovascular mortality (OR: 0.60, 95% CI: 0.40-0.76) in the group randomized to cardiac rehabilitation compared to a control intervention.

Findings of a large, multicenter RCT from the United Kingdom (U.K.) that evaluated the effectiveness of cardiac rehabilitation in a ‘real-life’ setting were published by West and colleagues in 2012. (6) Called the Rehabilitation After Myocardial Infarction Trial (RAMIT), the study included patients from centers with established cardiac rehabilitation programs that were multifactorial (including exercise, education and counseling), involved more than one discipline, and provided an intervention lasting a minimum of 10 hours. A total of 1,813 patients from 14 centers were randomized, 903 to cardiac rehabilitation and 910 to a control condition. Vital status was obtained at 2 years for 99.9% of participants (all but one patient) and at 7-9 years for 99.4% of participants. By 2 years, 166 patients had died, 82 (9.1%) in the cardiac rehabilitation group and 84 (9.2%) in the control group. The between-group difference in mortality at 2 years (the primary study outcome) was not statistically significant (RR: 0.98, 95% CI: 0.74 to 1.30). After 7-9 years, 488 patients had died, 245 (27%) in the cardiac rehabilitation group and 243 (26.7%) in the control group (RR: 0.99, 95% CI: 0.85-1.15). In addition, at 2 years, cardiovascular morbidity did not differ significantly between groups. For a combined endpoint including death, non-fatal MI, stroke or revascularization, the RR was 0.96 (95% CI: 0.88-1.07). In discussing the study’s negative findings, the trial authors noted that medical management of heart disease has improved over time, and patients in the control group may have had better outcomes than in earlier RCTs on this topic. Moreover, an editorial accompanying publication of study findings emphasized that RAMIT was not an efficacy trial but instead a trial evaluating the effectiveness of actual cardiac rehabilitation programs in the U.K. (7) Finally, these results may in part reflect the degree to which clinically based cardiac rehabilitation programs in the U.K. differ from the treatment protocols used in RCTs that were based in research settings.

Repeat Cardiac Rehabilitation

No studies were identified that evaluated the effectiveness of repeat participation in a cardiac rehabilitation program.

Summary

Cardiac rehabilitation refers to comprehensive medically supervised programs in the outpatient setting that aim to improve the function of patients with heart disease and prevent future cardiac events. A joint national U.S. guideline has specified core components of cardiac rehabilitation programs. Numerous RCTs have been performed, and meta-analyses of randomized controlled trials have found that cardiac rehabilitation improves health outcomes for selected patients. The evidence is insufficient to support repeat participation in cardiac rehabilitation programs.

Practice Guidelines and Position Statements

In 2007, the American Heart Association (AHA) and American Association of Cardiovascular and Pulmonary Rehabilitation (AACPR) issued an updated consensus statement on the core components of cardiac rehabilitation programs. (8) The 10 core components are: patient assessment prior to beginning the program, nutritional counseling, weight management, blood pressure management, lipid management, diabetes management, tobacco cessation, psychosocial management, physical activity counseling, and exercise training. Programs that only offer supervised exercise training are not considered to be cardiac rehabilitation. The updated guidelines specify the assessment, interventions, and expected outcomes for each of the core components. For example, symptom-limited exercise testing prior to exercise training is strongly recommended. The national guideline does not specify the optimal overall length of programs or number or duration of sessions.

In 2010, Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation published a position paper on cardiac rehabilitation. (2) Recommendations were based on a review of national guidelines from the U.S. and Europe. They stated that core components of cardiac rehabilitation are patient assessment, physical activity counseling, exercise training, diet/nutritional counseling, weight-control management, lipid management, blood pressure monitoring, smoking cessation, and psychosocial management. The recommended criteria for adequate exercise training are:

  • Mode: Continuous endurance e.g., walking, jogging, cycling, swimming, etc.
  • Duration: At least 20-30 minutes (preferably 45-60 minutes)
  • Frequency: Most days (at least 3 days per week and preferably 6-7 days per week)
  • Intensity: 50-80% of peak oxygen consumption or of peak heart rate or 40-60% of heart rate reserve.

The position paper did not address repeat participation in cardiac rehabilitation programs.

Coding

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps. 

ICD-9 Codes

89.44, 89.7, 93.36, 410.00-410.92, 412, 413.9, 428.0, V42.1, V45.81, V45.82

ICD-10 Codes

I20.8-I120.9, I21.01-I21.4, I50.1-I50.9, Z94.1, Z94.3, Z95.1, Z95.2-Z95.4, Z95.5, Z98.61

Procedural Codes: 93797, 93798, G0422, G0423, S9472
References
  1. Wegner NK, Froelicher ES, Smith LK. Cardiac Rehabilitation, Clinical Practice Guideline No. 17. US Dept of Health and Human Services AHCPR Publication No 96-0672 1995.
  2. Corra U, Piepoli MF, Carre F et al. Secondary prevention through cardiac rehabilitation: physical activity counselling and exercise training: key components of the position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation. Eur Heart J 2010; 31(16):1967-74.
  3. Heran BS, Chen JM, Ebrahim S et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev 2011; (7):CD001800.
  4. Davies EJ, Moxham T, Rees K et al. Exercise based rehabilitation for heart failure. Cochrane Database Syst Rev 2010; (4):CD003331.
  5. Lawler PR, Filion KB, Eisenberg MJ. Efficacy of exercise-based cardiac rehabilitation post-myocardial infarction: a systematic review and meta-analysis of randomized controlled trials. Am Heart J 2011; 162(4):571-84 e2.
  6. West RR, Jones DA, Henderson AH. Rehabilitation after myocardial infarction trial (RAMIT): multi-centre randomised controlled trial of comprehensive cardiac rehabilitation in patients following acute myocardial infarction. Heart 2012; 98(8):637-44.
  7. Doherty P, Lewin R. The RAMIT trial, a pragmatic RCT of cardiac rehabilitation versus usual care: what does it tell us? Heart 2012; 98(8):605-6.
  8. Balady GJ, Williams MA, Ades PA et al. Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation 2007; 115(20):2675-82.
  9. Cardiac Rehabilitation in the Outpatient Setting. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (June 2012) Therapy 8.03.08.
History
October 2010  Revised according to Health Care Reform. Maximum benefit limitations were removed. 
August 2012 Policy updated with literature review through April 2012. References 3, 5, 6 and 7 added; other references renumbered or removed. Added investigational policy statement. Medical necessity criteria still apply. No changes in coding. 
November 2013 Policy formatting and language revised.  Policy statement unchanged.  Added HCPCs codes G0422, G0423, and S9472.
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Cardiac Rehabilitation (CR)