PARTNERSHIP HEALTHPLAN OF CALIFORNIA
POLICY/ PROCEDURE
Policy/Procedure Number: MCUP3111 (Previously MPUP3111)
Policy/Procedure Title: Pulmonary Rehabilitation
Original Date: 10/20/2010
Lead Department: Health Services
☒External Policy
☐ Internal Policy
Next Review Date: 02/18/2016
Last Review Date: 02/18/2015
Applies to:
☒ Medi-Cal
☐ Healthy Kids
☐ Employees
Reviewing
Entities:
☒ IQI
☐P&T
☒ QUAC
☐ OPERATIONS
☐ EXECUTIVE
☐ COMPLIANCE
☐ DEPARTMENT
☐ BOARD
☐ COMPLIANCE
☐ FINANCE
☒ PAC
☐ CREDENTIALING
☐ DEPT. DIRECTOR/OFFICER
Approving
Entities:
☐ CEO
☐ COO
Approval Signature: Robert Moore, MD, MPH
Approval Date: 02/18/2015
I.
RELATED POLICIES:
A. MCUP3041 TAR Review Process
II.
IMPACTED DEPTS:
A. Health Services
B. Claims
C. Member Services
III.
DEFINITIONS:
A. N/A
IV.
ATTACHMENTS:
A. Pulmonary Rehabilitation Questionnaire
V.
PURPOSE:
To offer pulmonary rehabilitation as an enhanced PHC benefit for those members who meet the policy
criteria.
VI.
POLICY / PROCEDURE:
A. Pulmonary rehabilitation is defined as an evidence-based, multidisciplinary, and comprehensive
intervention for patients with chronic respiratory diseases who are symptomatic and often have
decreased daily life activities. The primary goal of pulmonary rehabilitation is to restore the patient to
the highest level of independent function by helping patients become more physically active, learn more
about their disease, treatment options, and how to cope.
B. All pulmonary rehabilitation requires prior authorization. The provider must submit the treatment
authorization request (TAR) for consideration.
C. The following codes may be used when applicable for TAR and claim submission:
1. G0237 – Pulmonary Therapeutic Procedure to Build Strength and Endurance
2. G0238 – Pulmonary Rehab 1:1
3. G0239 – Pulmonary Rehab Group Training
4. G0424 – Pulmonary Rehab Programs
5. 93041 – ECG Monitoring
Page 1 of 3
Policy/Procedure Number: MCUP3111 (Previously
MPUP3111)
Lead Department: Health Services
☒ External Policy
☐ Internal Policy
Next Review Date: 02/18/2016
Last Review Date: 02/18/2015
☐ Healthy Kids
☐ Employees
Policy/Procedure Title: Pulmonary Rehabilitation
Original Date: 10/20/2010
Applies to:
☒ Medi-Cal
D. Members eligible for this benefit must meet the following criteria, and a completed Pulmonary
Rehabilitation Questionnaire must be submitted with the TAR.
1. Chronic Obstructive Pulmonary Disease (COPD
a. Severe, at least stage II COPD, by FEV1 of less than 60% of predicted value and DLCO of less
than 60% of predicted. Pulmonary Function Testing (PFT) results must be submitted with TAR.
b. Decreased quality of life due to problems with control of COPD.
c. Worsening pulmonary symptoms.
d. Maximized pharmaceutical treatment.
e. No longer smoking cigarettes or at least actively quitting by evidence of use of tobacco
cessation product.
2. Interstitial lung disease (ILD) or idiopathic pulmonary fibrosis (IPF)
a. Dx of ILD or Idiopathic pulmonary fibrosis.
b. FEV1/FVC >70% of predicted.
c. TLC <60% of predicted.
d. Decreased quality of life due to problems with control of COPD.
e. Worsening pulmonary symptoms.
f. Maximized pharmaceutical treatment.
g. DLCO of less than 60% of predicted
E. Members who meet the criteria will initially be approved up to a maximum of 24 visits. Additional
visits can be requested with evidence of compliance combined with improvements and benefits of
pulmonary rehabilitation.
VII.
REFERENCES:
A. 2007 Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines for Pulmonary Rehabilitation,
Effects of Pulmonary Rehabilitation in Patients with Restrictive Lung Diseases, Salhi,B et.al. CHEST
/137/2/February, 2010
B. Benefit approved by Board Resolution number 10.5, dated January 26, 2011
VIII.
DISTRIBUTION:
A. Provider Manual
B. PHC Directors
IX.
POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Senior Director, Health Services
X.
REVISION DATES:
Medi-Cal
03/21/12; 02/18/15
PREVIOUSLY APPLIED TO:
PartnershipAdvantage:
MPUP3111 - 10/20/2010 to 01/01/2015
Page 2 of 3
Policy/Procedure Number: MCUP3111 (Previously
MPUP3111)
Lead Department: Health Services
☒ External Policy
☐ Internal Policy
Next Review Date: 02/18/2016
Last Review Date: 02/18/2015
☐ Healthy Kids
☐ Employees
Policy/Procedure Title: Pulmonary Rehabilitation
Original Date: 10/20/2010
Applies to:
☒ Medi-Cal
*********************************
In accordance with the California Health and Safety Code, Section 1363.5, this policy was developed with
involvement from actively practicing health care providers and meets these provisions:



Consistent with sound clinical principles and processes
Evaluated and updated at least annually
If used as the basis of a decision to modify, delay or deny services in a specific case, the criteria will be
disclosed to the provider and/or enrollee upon request
The materials provided are guidelines used by PHC to authorize, modify or deny services for persons with similar
illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits
covered under PHC.
Page 3 of 3