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Aetna Aetna
Clinical Policy Bulletin:
Cardiac Rehabilitation
Number: 0021


Policy

Aetna considers outpatient cardiac rehabilitation medically necessary as described below.

The following selection criteria represent implementation of guidelines established by the American College of Physicians, the American College of Cardiology, and the Agency for Healthcare Research and Quality (AHRQ) Health Technology Assessment.

Eligibility:

Aetna considers a medically supervised cardiac rehabilitation program medically necessary for selected members when it is individually prescribed by a physician within a 12 month window after any of the following:

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

Aetna considers cardiac rehabilitation experimental and investigational for all other indications (individuals who are too debilitated to exercise, and secondary prevention after transient ischemic attack or mild, non-disabling stroke) because of insufficient evidence in the peer-reviewed literature.

Frequency and Duration

The medically necessary frequency and duration of cardiac rehabilitation is determined by the member’s level of cardiac risk stratification:

  1. High-risk members have any of the following:

    • Decrease in systolic blood pressure of 15 mm Hg or more with exercise; or
    • Exercise test limited to less than or equal to 5 metabolic equivalents (METS); or
    • Marked exercise-induced ischemia, as indicated by either anginal pain or 2 mm or more ST depression by electrocardiography (ECG); or
    • Recent myocardial infarction (less than 6 months) which was complicated by serious ventricular arrhythmia, cardiogenic shock or congestive heart failure; or
    • Resting complex ventricular arrhythmia; or
    • Severely depressed left ventricular function (ejection fraction less than 30 %); or
    • Survivor of sudden cardiac arrest; or
    • Ventricular arrhythmia appearing or increasing with exercise or occurring in the recovery phase of stress testing.

    Program Description for High-Risk Members:

    • 36 sessions (e.g., 3 times per week for 12 weeks) of supervised exercise with continuous telemetry monitoring
    • Create an individual out-patient exercise program that can be self-monitored and maintained
    • Educational program for risk factor/stress reduction
    • If no clinically significant arrhythmia is documented during the first 3 weeks of the program, the provider may have the member complete the remaining portion without telemetry monitoring.
  2. Intermediate-risk members have any of the following:

    • Exercise test limited to 6-9 METS; or
    • Ischemic ECG response to exercise of less than 2 mm of ST depression; or
    • Uncomplicated myocardial infarction, coronary artery bypass surgery, or angioplasty and has a post-cardiac event maximal functional capacity of 8 METS or less on ECG exercise test.

    Program Description for Intermediate-Risk Members:

    • 24 sessions or less of exercise training without continuous ECG monitoring (see exit criteria below, as some members may only require fewer than 3 weekly visits and/or less than 8 weeks)*
    • Geared to define an ongoing exercise program that is "self-administered."
  3. Low-risk members have exercise test limited to greater than 9 METS

    Program Description for Low-Risk Members:

    1. 6 1-hour sessions involving risk factor reduction education and supervised exercise to show safety and define a home program (e.g., 3 times per week for a total of 2 weeks or 2 sessions per week for 3 weeks).

Aetna considers additional cardiac rehabilitation services medically necessary based on the above-listed criteria when the member has any of the following conditions:

  1. Another cardiovascular surgery or angioplasty; or
  2. Another documented myocardial infarction or extension of initial infarction; or
  3. New clinically significant coronary lesions documented by cardiac catheterization; or
  4. New evidence of ischemia on an exercise test, including thallium scan.

* Physician supervision is of no proven value for non-EKG monitored cardiac rehabilitation and is therefore considered experimental and investigational because of insufficient evidence in the peer-reviewed literature.



Background

Patients who have cardiovascular events are often functional in society and employed prior to a cardiac event, and frequently require only re-entry into their former life pattern.  Cardiac rehabilitation serves this purpose by providing a supervised program in the outpatient setting that involves medical evaluation, an ECG-monitored physical exercise program, cardiac risk factor modification, education, and counseling.

Traditionally, cardiac rehabilitation programs have been classified into 4 phases, phase I to IV, representing a progression from the hospital (phase I) to a medically supervised out-patient program (phases II and III) to a community or home-based setting (phase IV).  Due to changes in hospital and health care practices, and the need to accommodate patients at various stages of disease risk, the need for phase designation becomes inappropriate.  Cardiac rehabilitation programs can be more appropriately distinguished as inpatient, outpatient or community/home-based programs.  Participation within these programs is determined by appropriate risk stratification in order to maximize health care resources and patient benefit.  Irrespective of the program, there should be regular communication, in the form of progress reports, between the program staff and the patient’s attending physician (Ignaszewski and Lear, 1998).

Entry into such programs is based on the demonstrated limitation of functional capacity on exercise stress testing, and the expectation that medically supervised exercise training will improve functional capacity to a clinically significant degree.  The exercise test in cardiac rehabilitation is a vital component of the overall rehabilitative process as it provides continuous follow-up in a noninvasive manner and adds information to the overall physical evaluation.  In general, testing is performed before entering the cardiac rehabilitation exercise program, and sequentially during the program to provide information on the changes in cardiac status, prognosis, functional capacity, and evidence of training effect.  The central component of cardiac rehabilitation is a prescribed regimen of physical exercises intended to improve functional work capacity and to increase the patient's confidence and well-being.  Depending on the degree of debilitation, cardiac patients may or may not require a full or supervised rehabilitation program.

The scientific literature documents that some of the benefits of participation in a cardiac rehabilitation program include decreased symptoms of angina pectoris, dyspnea, and fatigue, and improvement in exercise tolerance, blood lipid levels, and psychosocial well-being, as well as a reduction in weight, cigarette smoking and stress.  The efficacy of modification of risk factors in reducing the progression of coronary artery disease and future morbidity and mortality has been established.  Meta-analysis of data from random controlled studies indicates a 20 % to 25 % reduction in mortality in patients participating in cardiac rehabilitation following myocardial infarction as compared to controls.

The typical model for delivering outpatient cardiac rehabilitation in the United States is for patients to attend sessions 2 to 3 times per week for up to 12 to 18 weeks (36 total sessions) (CMS, 2006).  A session typically lasts for approximately 1 hour and includes aerobic and/or resistance exercises with continuous electro-cardiographic monitoring.  There are alternative approaches to this typical model.  Patients can be classified as low-, moderate- or high-risk for participating in exercise based on a combination of clinical and functional data.  The number of recommended supervised exercise sessions varies by risk level: low-risk patients receive 6 to 18 exercise sessions over 30 days or less from the date of the cardiac event/procedure; moderate-risk 12 to 24 sessions over 60 days; and high-risk 18 to 36 sessions over 90 days (Hamm, 2008; AACVPR, 2004).

There is limited evidence on the appropriate duration of cardiac rehabilitation.  Hammill et al (2010) stated that for patients with coronary heart disease, exercise-based cardiac rehabilitation improves survival rate and has beneficial effects on risk factors for coronary artery disease.  However, the relationship between the number of sessions attended and long-term outcomes is unknown.  In a national 5 % sample of Medicare beneficiaries, these investigators identified 30,161 elderly patients who attended at least 1 cardiac rehabilitation session between January 1, 2000, and December 31, 2005.  They used a Cox proportional hazards model to estimate the relationship between the number of sessions attended and death and myocardial infarction (MI) at 4 years.  The cumulative number of sessions was a time-dependent co-variate.  After adjustment for demographical characteristics, co-morbid conditions, and subsequent hospitalization, patients who attended 36 sessions had a 14 % lower risk of death (hazard ratio [HR], 0.86; 95 % confidence interval [CI]: 0.77 to 0.97) and a 12 % lower risk of MI (HR, 0.88; 95 % CI: 0.83 to 0.93) than those who attended 24 sessions; a 22 % lower risk of death (HR, 0.78; 95 % CI: 0.71 to 0.87) and a 23 % lower risk of MI (HR, 0.77; 95 % CI: 0.69 to 0.87) than those who attended 12 sessions; and a 47 % lower risk of death (HR, 0.53; 95 % CI: 0.48 to 0.59) and a 31 % lower risk of MI (HR, 0.69; 95 % CI: 0.58 to 0.81) than those who attended 1 session.  The authors concluded that among Medicare beneficiaries, a strong dose-response relationship existed between the number of cardiac rehabilitation sessions and long-term outcomes.  Attending all 36 sessions reimbursed by Medicare was associated with lower risks of death and MI at 4 years compared with attending fewer sessions.

Prior and colleagues (2011) tested feasibility and effectiveness of 6-month outpatient comprehensive cardiac rehabilitation (CCR) for secondary prevention after transient ischemic attack or mild, non-disabling stroke.  Consecutive consenting subjects having sustained a transient ischemic attack or mild, non-disabling stroke within the previous 12 months (mean of 11.5 weeks; event-to-CCR entry) with greater than or equal to 1 vascular risk factor, were recruited from a stroke prevention clinic providing usual care.  These researchers measured 6-month CCR outcomes following a prospective cohort design.  Of 110 subjects recruited from January 2005 to April 2006, 100 subjects (mean age of 64.9 years; 46 women) entered and 80 subjects completed CCR.  These investigators obtained favorable, significant intake-to-exit changes in: aerobic capacity (+31.4 %; p < 0.001), total cholesterol (-0.30 mmol/L; p = 0.008), total cholesterol/high-density lipoprotein (-11.6 %; p < 0.001), triglycerides (-0.27 mmol/L; p = 0.003), waist circumference (-2.44 cm; p < 0.001), body mass index (-0.53 kg/m(2); p = 0.003), and body weight (-1.43 kg; p = 0.001).  Low-density lipoprotein (-0.24 mmol/L), high-density lipoprotein (+0.06 mmol/L), systolic (-3.21 mm Hg) and diastolic (-2.34 mm Hg) blood pressure changed favorably, but non-significantly.  A significant shift toward non-smoking occurred (p = 0.008).  Compared with intake, 11 more individuals (25.6 % increase) finished CCR in the lowest-mortality risk category of the Duke Treadmill Score (p < 0.001).  The authors concluded that CCR is feasible and effective for secondary prevention after transient ischemic attack or mild, non-disabling stroke, offering a promising model for vascular protection across chronic disease entities.  The authors stated that they know of no similar previous investigation, and are now conducting a randomized trial.

 

Appendix

Note on Exit Criteria

The following clinical exit criteria have been identified as acceptable (CMS, 1989):

  • Symptoms of angina or dyspnea are stable at the patients maximum exercise level; and
  • The patient has achieved a stable level of exercise tolerance without ischemia or dysrhythmia; and
  • The patient's resting blood pressure and heart rate are within normal limits; and
  • The stress test is not positive during exercise (A positive stress test in this context implies an ECG with a junctional depression of 2 mm or more associated with slowly rising, horizontal, or down sloping ST segment).
 
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
93798
CPT codes not covered for indications listed in the CPB:
93797
Other CPT codes related to the CPB:
93015- 93024
93451- 93454
HCPCS codes covered if selection criteria are met:
G0422 Intensive cardiac rehabilitation; with or without continuous ECG monitoring with exercise, per session
S9472 Cardiac rehabilitation program, non-physician provider, per diem
HCPCS codes not covered for indications listed in the CPB:
G0423 Intensive cardiac rehabilitation; with or without continuous ECG monitoring; without exercise, per session
Other HCPCS codes related to the CPB:
S9449 Weight management classes, non-physician provider, per session
S9451 Exercise classes, non-physician provider, per session
S9452 Nutrition classes, non-physician provider, per session
S9453 Smoking cessation classes, non-physician provider, per session
S9454 Stress management classes, non-physician provider, per session
S9470 Nutritional counseling, dietitian visit
ICD-9 codes covered if selection criteria are met:
392.0 Rheumatic chorea with heart involvement
394 - 397.9 Diseases of mitral valve, diseases of aortic valve, diseases of mitral and aortic valves, and diseases of other endocardial structures
398.91 Rheumatic heart failure (congestive)
402.01 Hypertensive heart disease, malignant, with heart failure
402.11 Hypertensive heart disease, benign, with heart failure
402.91 Hypertensive heart disease, unspecified, with heart failure
404.01 Hypertensive heart and chronic kidney disease, malignant, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified
404.03 Hypertensive heart and chronic kidney disease, malignant, with heart failure and chronic kidney disease stage V or end stage renal disease
404.11 Hypertensive heart and chronic kidney disease, benign, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified
404.13 Hypertensive heart and chronic kidney disease, benign, with heart failure and chronic kidney disease stage V or end stage renal disease
404.91 Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified
404.93 Hypertensive heart and chronic kidney disease, unspecified, with heart failure and chronic kidney disease stage V or end stage renal disease
410.00 - 414.9 Ischemic heart disease
424.0 - 424.3 Mitral valve disorders, aortic valve disorders, tricuspid valve disorders, specified as non-rheumatic, and pulmonary valve disorders
425.0 - 425.9 Cardiomyopathy
427.1 Paroxysmal ventricular tachycardia
427.2 Paroxysmal tachycardia, unspecified
427.41 Ventricular fibrillation
427.42 Ventricular flutter
427.5 Cardiac arrest
428.0 - 428.9 Heart failure
429.4 Functional disturbances following cardiac surgery
V15.1 Surgery to heart and great vessels
V42.1 Organ or tissue replaced by transplant, heart
V42.2 Organ or tissue replaced by transplant , heart valve
V42.6 Organ or tissue replaced by transplant, lung
V43.21 Organ or tissue replaced by other means, heart assist device
V43.22 Organ or tissue replaced by other means, fully implantable artificial heart
V43.3 Organ or tissue replaced by other means, heart valve
V45.81 Aortocoronary bypass status
V45.82 Percutaneous transluminal coronary angioplasty status
V45.89 Other postprocedural status
V57.21 Encounter for occupational therapy
V57.89 Other specified rehabilitation procedure
ICD-9 codes not covered for indications listed in the CPB (not all-inclusive)::
V12.54 Personal history of transient ischemic attack [TIA], and cerebral infarction without residual deficits [not covered when used to report secondary prevention after transient ischemic attack or mild, non-disabling stroke]


The above policy is based on the following references:
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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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