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 24-week (6-month) window 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. 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).

Aetna considers cardiac rehabilitation experimental and investigational for all other indications.

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:

   • 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 ECG; or
   • Severely depressed left ventricular function (ejection fraction less than 30 %); or
   • Resting complex ventricular arrhythmia; or
   • Ventricular arrhythmia appearing or increasing with exercise or occurring in the recovery phase of stress testing; or
   • Decrease in systolic blood pressure of 15 mm Hg or more with exercise; or
   • Recent myocardial infarction (less than 6 months) which was complicated by serious ventricular arrhythmia, cardiogenic shock or congestive heart failure; or

   • Survivor of sudden cardiac arrest.

   Program Description for High Risk Members:

   • 36 sessions (e.g., 3x/week for 12 weeks) of supervised exercise with continuous telemetry monitoring
   • Educational program for risk factor/stress reduction
   • Create an individual out-patient exercise program that can be self-monitored and maintained

   • If no clinically significant arrhythmia is documented during the first three 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 one-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 two weeks or two sessions per week for three 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 documented myocardial infarction or extension of initial infarction; or
2. Another cardiovascular surgery or angioplasty; or
3. New evidence of ischemia or an exercise test, including thallium scan; or
4. New clinically significant coronary lesions documented by cardiac catheterization.

* Physician supervision is of no proven value for non-EKG monitored cardiac rehabilitation and is therefore considered experimental and investigational.

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.

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.

Note on Exit Criteria

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

• The patient has achieved a stable level of exercise tolerance without ischemia or dysrhythmia; and
• Symptoms of angina or dyspnea are stable at the patients maximum exercise level; 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 2mm or more associated with slowly rising, horizontal, or down sloping ST segment).