PARTNERSHIP HEALTHPLAN OF CALIFORNIA
POLICY/ PROCEDURE
Policy/Procedure Number: MCUP3128
Lead Department: Health Services
☒External Policy
☐ Internal Policy
Policy/Procedure Title: Cardiac Rehabilitation
Original Date: 02/18/2015
Effective Date: 08/01/2015
Next Review Date: 06/17/2016
Last Review Date: 06/17/2015
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: 06/17/2015
Effective Date: 08/01/2015
I.
RELATED POLICIES:
A. MCUP3052 – Medical Nutrition
B. MCUP3041 – TAR Review Process
II.
IMPACTED DEPTS:
A. Health Services
B. Claims
C. Member Services
III.
DEFINITIONS:
A. Cardiac rehabilitation is a medically supervised program that helps improve the health and well-being of
people who have heart problems. Phase I cardiac rehabilitation takes place during the acute
hospitalization or in an acute rehabilitation setting, of the index diagnosis. Phase II cardiac rehabilitation
takes place in a monitored, supervised outpatient setting. Phases III cardiac rehab takes place in an
outpatient setting, in a supervised environment without cardiac monitoring, including organized group
classes. Phase IV cardiac rehab is a lifetime maintenance of physical conditioning, fitness and wellness,
either at home, or other community-based setting.
B. Cardiac rehabilitation programs provide cardiac rehabilitation, including exercise training, education on
heart healthy living, and counseling to reduce stress and help you return to an active life
IV.
ATTACHMENTS:
A. N/A
V.
PURPOSE:
This policy defines covered services and medical necessity criteria for cardiac rehabilitation services.
Cardiac rehabilitation services have been found to reduce morbidity and mortality from cardiovascular
disease (see references, below).
VI.
POLICY / PROCEDURE:
A. Eligibility
1. Adults with full-scope Medi-Cal are eligible for Phase II Cardiac Rehabilitation services, with the
following diagnoses:
a. Heart attack (myocardial infarction) in the past 12 months
b. Coronary artery bypass surgery in the past 12 months
c. Current stable angina pectoris
Page 1 of 7
Policy/Procedure Number: MCUP3128
Lead Department: Health Services
☒ External Policy
☐ Internal Policy
Next Review Date: 06/17/2016
Last Review Date: 06/17/2015
☐ Healthy Kids
☐ Employees
Policy/Procedure Title: Cardiac Rehabilitation
Original Date: 02/18/2015
Effective Date: 08/01/2015
Applies to: ☒ Medi-Cal
d.
e.
f.
g.
2.
3.
4.
5.
Heart valve repair or replacement in the past 12 months.
Coronary angioplasty performed or coronary stent placed in the last 12 months.
A heart or heart-lung transplant in the last 12 months
Stable chronic heart failure with ejection fraction of less than 35% and New York Heart
Association (NYHA) class II to IV symptoms in spite of optimal therapy for at least 6 weeks.
h. Other cardiac or major pulmonary surgery.
Phase II services are only covered when ordered by a licensed physician and when performed in a
facility/program meeting Medicare’s standards for cardiac rehabilitation programs. These standards
include:
a. The facility meets the definition of a hospital outpatient department or a physician-directed
facility.
b. The facility has available for immediate use all the necessary cardio-pulmonary emergency and
therapeutic life-saving equipment to perform defibrillation, administer oxygen and perform
cardiopulmonary resuscitation.
c. The program is conducted in an area set aside for the exclusive use of the program while it is in
session.
d. The program is staffed by personnel necessary to conduct the program safely and effectively,
who are trained in both basic and advanced life support techniques and in exercise therapy for
coronary disease.
e. Services of nonphysician personnel must be furnished under the direct supervision of a
physician. Direct supervision means that a physician must be in the exercise program area or
immediately available and accessible for an emergency at all times the exercise program is
conducted. It does not require that a physician be physically present in the exercise room itself,
provided the contractor does not determine that the physician is too remote from the patients'
exercise area to be considered immediately available and accessible. The examples below are
for illustration purposes only. They are not meant to limit the discretion of the contractor to
make determinations in this regard.
f. The nonphysician personnel are employees of either the physician, hospital, or facility
conducting the program and their services are "incident-to a physician's professional services.
Prior to referral for Phase II cardiac rehabilitation services, a cardiologist or primary care physician
with experience and training in evaluation and assessment of cardiovascular disease must complete a
diagnostic evaluation of the prospected cardiac rehabilitation participant. This will include:
a. Evaluation of chest pain and atypical chest pain. This may include performance of a cardiac
stress test or review of a recent stress test
b. Pre or post-operative evaluation of cardiac operations (if applicable)
c. Review and reconciliation of all medications
d. Review of medical history, including social history, medical history, surgical history
e. Specific recommendations for the exercise regimen to be used in the cardiac rehabilitation
program. This can lead to either a prescription or a referral to cardiac rehabilitation. PHC does
not requires submission of a Referral Authorization Form (RAF), but may audit medical records
for evidence of this documentation.
A Treatment Authorization Request (TAR) is required for Phase II cardiac rehabilitation
services.
PHC considers cardiac rehabilitation experimental and investigational and therefore not a benefit 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 peerreviewed.
Page 2 of 7
Policy/Procedure Number: MCUP3128
Lead Department: Health Services
☒ External Policy
☐ Internal Policy
Next Review Date: 06/17/2016
Last Review Date: 06/17/2015
☐ Healthy Kids
☐ Employees
Policy/Procedure Title: Cardiac Rehabilitation
Original Date: 02/18/2015
Effective Date: 08/01/2015
Applies to: ☒ Medi-Cal
B. Covered Services
1. Phase I cardiac rehabilitation services are performed while the PHC member is in the acute hospital
or acute rehab setting. They are integral to the inpatient care provided to PHC members for
appropriate indications.
2. Phase II cardiac rehabilitation services are performed in an outpatient setting. Services may include:
a. medically-supervised exercise program
b. nutritional counseling
c. stress management
d. smoking cessation counseling and support services
3. Phases III and IV cardiac rehabilitation, by themselves, are not covered.
4. Phase II cardiac rehabilitation services do not include the diagnostic evaluation that is required prior
to referral to cardiac rehabilitation, which is covered separately.
5. The medically necessary frequency and duration of cardiac rehabilitation is determined by the
member’s level of cardiac risk stratification:
a. High-risk members have any of the following:
1) Decrease in systolic blood pressure of 15 mm Hg or more with exercise; or
2) Exercise test limited to less than or equal to 5 metabolic equivalents (METS); or
3) marked exercise-induced ischemia, as indicated by either anginal pain or 2 mm or more ST
depression by electrocardiography (ECG); or
4) Recent myocardial infarction (less than 6 months) which was complicated by serious
ventricular arrhythmia, cardiogenic shock or congestive heart failure; or
5) Resting complex ventricular arrhythmia; or
6) Severely depressed left ventricular function (ejection fraction less than 30 %); or
7) Survivor of sudden cardiac arrest; or
8) Ventricular arrhythmia appearing or increasing with exercise or occurring in the recovery
phase of stress testing.
b. Program Description for High-Risk Members:
1) 36 sessions (e.g., 3 times per week for 12 weeks) of supervised exercise with continuous
telemetry monitoring
2) Create an individual out-patient exercise program that can be self-monitored and maintained
3) Educational program for risk factor/stress reduction; classes listed below covered for up to 3
months.
4) 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.
c. Intermediate-risk members have any of the following:
1) Exercise test limited to 6-9 METS; or
2) Ischemic ECG response to exercise of less than 2 mm of ST depression; or
3) 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.
d. Program Description for Intermediate-Risk Members:
1) 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)*
2) Geared to define an ongoing exercise program that is "self-administered."
3) Educational program for risk factor/stress reduction; classes listed below covered for up to 3
months.
Page 3 of 7
Policy/Procedure Number: MCUP3128
Lead Department: Health Services
☒ External Policy
☐ Internal Policy
Next Review Date: 06/17/2016
Last Review Date: 06/17/2015
☐ Healthy Kids
☐ Employees
Policy/Procedure Title: Cardiac Rehabilitation
Original Date: 02/18/2015
Effective Date: 08/01/2015
Applies to: ☒ Medi-Cal
e.
f.
Low-risk members have exercise test limited to greater than 9 METS
Program Description for Low-Risk Members:
1) Six 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).
2) Educational program for risk factor/stress reduction; classes listed below covered for up to 3
months.
6. Procedure codes covered:
a. 93797 -- Physician or other qualified health care professional services for outpatient cardiac
rehabilitation; without continuous ECG Monitoring (For intermediate-risk and low-risk
members)
b. 93798 -- Physician or other qualified health care professional services for outpatient cardiac
rehabilitation; with continuous ECG Monitoring (for high-risk members)
c. S9449 – Weight management classes, non-physician provider, per session
d. S9451 – Exercise classes, non-physician provider, per session
e. S9453 – Smoking cessation classes, non-physician provider, per session
f. S9454 – Stress management, non-physician provider, per session
g. Nutrition Therapy services are also covered, as defined in MCUP3052
VII.
REFERENCES:
A. Ades PA. Cardiac rehabilitation and secondary prevention of coronary heart disease. N Engl J Med.
2001;345(12):892-902.
B. American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR). Guidelines for
Cardiac Rehabilitation and Secondary Prevention Programs. 4th ed. Champaign, IL: Human Kinetics;
2004.
C. American Association of Cardiovascular and Pulmonary Rehabilitation; American College of
Cardiology Foundation; American Heart Association Task Force on Performance Measures (Writing
Committee to Develop Clinical Performance Measures for Cardiac Rehabilitation), Thomas RJ, King M,
Lui K, et al. AACVPR/ACCF/AHA 2010 Update: Performance Measures on Cardiac Rehabilitation for
Referral to Cardiac Rehabilitation / Secondary Prevention Services Endorsed by the American College
of Chest Physicians, the American College of Sports Medicine, the American Physical Therapy
Association, the Canadian Association of Cardiac Rehabilitation, the Clinical Exercise Physiology
Association, the European Association for Cardiovascular Prevention and Rehabilitation, the InterAmerican Heart Foundation, the National Association of Clinical Nurse Specialists, the Preventive
Cardiovascular Nurses Association, and the Society of Thoracic Surgeons. J Am Coll Cardiol.
2010;56(14):1159-1167.
D. American College of Cardiology (ACC). Cardiovascular Rehabilitation. ACC Position Statement.
Bethesda, MD: ACC; 1985:1-6. Available at: http://www.acc.org/clinical/position/72539.pdf. Accessed
January 19, 2006.
E. Arnold JM, Liu P, Demers C, et al; Canadian Cardiovascular Society. Canadian Cardiovascular Society
consensus conference recommendations on heart failure 2006: Diagnosis and management. Can J
Cardiol. 2006;22(1):23-45.
F. Austin J, Williams WR, Ross L, Hutchison S. Five-year follow-up findings from a randomized
controlled trial of cardiac rehabilitation for heart failure. Eur J Cardiovasc Prev Rehabil. 2008;15(2):162167.
G. Balady GJ, Ades PA, Comoss P, et al. Core components of cardiac rehabilitation/secondary prevention
programs: A statement for healthcare professionals from the American Heart Association and the
American Association of Cardiovascular and Pulmonary Rehabilitation Writing Group. Circulation.
2000;102(9):1069-1073.
Page 4 of 7
Policy/Procedure Number: MCUP3128
Lead Department: Health Services
☒ External Policy
☐ Internal Policy
Next Review Date: 06/17/2016
Last Review Date: 06/17/2015
☐ Healthy Kids
☐ Employees
Policy/Procedure Title: Cardiac Rehabilitation
Original Date: 02/18/2015
Effective Date: 08/01/2015
Applies to: ☒ Medi-Cal
H. Balady GJ, Fletcher BJ, Froelicher ES, et al. AHA Medical/Scientific Statement. Cardiac Rehabilitation
Programs. Dallas, TX: American Heart Association (AHA); 1994.
I. Beauchamp A, Worcester M, Ng A, et al. Attendance at cardiac rehabilitation is associated with lower
all-cause mortality after 14 years of follow-up. Heart. 2013;99(9):620-625.
J. Brown A, Noorani H, Taylor R, et al. A clinical and economic review of exercise-based cardiac
rehabilitation programs for coronary artery disease. Technology Overview No. 11. Ottawa, ON:
Canadian Coordinating Office for Health Technology Assessment (CCOHTA); August 2003.
K. Canyon S, Meshgin N. Cardiac rehabilitation - reducing hospital readmissions through community based
programs. Aust Fam Physician. 2008;37(7):575-577.
L. Ceci V, Chieffo C, Giannuzzi P, et al. Standards and guidelines for cardiac rehabilitation. Working
Group on Cardiac Rehabilitation of the European Society for Cardiology. Cardiologia. 1999;44(6):579584.
M. Centers for Disease Control and Prevention (CDC). Receipt of outpatient cardiac rehabilitation among
heart attack survivors--United States, 2005. MMWR Morb Mortal Wkly Rep. 2008;57(4):89-94.
N. Centers for Medicare & Medicaid Services (CMS). Decision memo for cardiac rehabilitation (CR)
programs - chronic heart failure (CAG-00437N). Medicare Coverage Database. Baltimore, MD: CMS;
February 18, 2014
O. Centers for Medicare and Medicaid Services (CMS). NCD for cardiac rehabilitation programs.
P. Cooper AF, Jackson G, Weinman J, Horne R. Factors associated with cardiac rehabilitation attendance:
A systematic review of the literature. Clin Rehabil. 2002;16(5):541-552.
Q. Davies EJ, Moxham T, Rees K, et al. Exercise based rehabilitation for heart failure. Cochrane Database
Syst Rev. 2010;(4):CD003331.
R. Fernandez RS, Davidson P, Griffiths R, et al. A pilot randomised controlled trial comparing a healthrelated lifestyle self-management intervention with standard cardiac rehabilitation following an acute
cardiac event: Implications for a larger clinical trial. Aust Crit Care. 2009;22(1):17-27.
S. Forman DE, Farquhar W. Cardiac rehabilitation and secondary prevention programs for elderly cardiac
patients. Clin Geriatr Med. 2000;16(3):619-629.
T. Giannuzzi P, Saner H, Bjornstad H, et al. Secondary prevention through cardiac rehabilitation: Position
paper of the Working Group on Cardiac Rehabilitation and Exercise Physiology of the European Society
of Cardiology. Eur Heart J. 2003;24(13):1273-1278.
U. Gordon NF, Gulanick M, Costa F, et al. Physical activity and exercise recommendations for stroke
survivors: An American Heart Association scientific statement from the Council on Clinical Cardiology,
Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention; the Council on Cardiovascular
Nursing; the Council on Nutrition, Physical Activity, and Metabolism; and the Stroke Council.
Circulation. 2004;109(16):2031-2041.
V. Hamm LF. Cardiac rehabilitation in the United States: From evidence to application. Kardiol Pol.
2008;66:921-924.
W. Hammill BG, Curtis LH, Schulman KA, Whellan DJ. Relationship between cardiac rehabilitation and
long-term risks of death and myocardial infarction among elderly Medicare beneficiaries. Circulation.
2010;121(1):63-70.
X. Institute for Clinical Systems Improvement (ICSI). Cardiac rehabilitation. Technology Assessment
Report. Bloomington, MN: ICSI; 2002.
Y. Isaksen K, Morken IM, Munk PS, Larsen AI. Exercise training and cardiac rehabilitation in patients with
implantable cardioverter defibrillators: A review of current literature focusing on safety, effects of
exercise training, and the psychological impact of programme participation. Eur J Cardiovasc Prev
Rehabil. 2012;19(4):804-812.
Z. Jolliffe JA, Rees K, Taylor RS, et al. Exercise-based rehabilitation for coronary heart disease. Cochrane
Database Syst Rev. 2001;(1):CD001800.
Page 5 of 7
Policy/Procedure Number: MCUP3128
Lead Department: Health Services
☒ External Policy
☐ Internal Policy
Next Review Date: 06/17/2016
Last Review Date: 06/17/2015
☐ Healthy Kids
☐ Employees
Policy/Procedure Title: Cardiac Rehabilitation
Original Date: 02/18/2015
Effective Date: 08/01/2015
Applies to: ☒ Medi-Cal
AA.Jolly K, Taylor RS, Lip GY, Stevens A. Home-based cardiac rehabilitation compared with centre-based
rehabilitation and usual care: A systematic review and meta-analysis. Int J Cardiol. 2006;111(3):343351.
BB. King M, Bittner V, Josephson R, et al. Medical director responsibilities for outpatient cardiac
rehabilitation/secondary prevention programs: 2012 update: A statement for health care professionals
from the American Association of Cardiovascular and Pulmonary Rehabilitation and the American Heart
Association. Circulation. 2012;126(21):2535-2543.
CC. National Institute for Health and Clinical Excellence (NICE). Secondary prevention in primary and
secondary care for patients following a myocardial infarction. NICE Clinical Guideline 48. London, UK:
NICE; May 2007.
DD.New Zealand Guidelines Group (NZGG). Cardiac rehabilitation. Evidence-Based Best Practice
Guideline. Wellington, New Zealand: NZGG; August 2002.
EE. Pack QR, Mansour M, Barboza JS, et al. An early appointment to outpatient cardiac rehabilitation at
hospital discharge improves attendance at orientation: A randomized, single-blind, controlled trial.
Circulation. 2013;127(3):349-355.
FF. Piepoli MF, Corrà U, Benzer W, et al; Cardiac Rehabilitation Section of the European Association of
Cardiovascular Prevention and Rehabilitation. Secondary prevention through cardiac rehabilitation:
From knowledge to implementation. A position paper from the Cardiac Rehabilitation Section of the
European Association of Cardiovascular Prevention and Rehabilitation. Eur J Cardiovasc Prev Rehabil.
2010;17(1):1-17.
GG.Prior PL, Hachinski V, Unsworth K, et al. Comprehensive cardiac rehabilitation for secondary
prevention after transient ischemic attack or mild stroke: I: Feasibility and risk factors. Stroke.
2011;42(11):3207-3213.
HH.Rees K, Taylor RS, Singh S, et al. Exercise based rehabilitation for heart failure. Cochrane Database
Syst Rev. 2004,(3):CD003331.
II. Skinner JS, Cooper A, Feder GS; Guideline Development Group. Secondary prevention for patients
following a myocardial infarction: Summary of NICE guidance. Heart. 2007;93(7):862-864.
JJ. Stewart KJ, Badenhop D, Brubaker PH, et al. Cardiac rehabilitation following percutaneous
revascularization, heart transplant, heart valve surgery, and for chronic heart failure. Chest.
2003;123(6):2104-2111.
KK. Taylor RS, Brown A, Ebrahim S, et al. Exercise-based rehabilitation for patients with coronary heart
disease: Systematic review and meta-analysis of randomized controlled trials. Am J Med. 2004;116:682–
692.
LL. Taylor RS, Dalal H, Jolly K, et al. Home-based versus centre-based cardiac rehabilitation. Cochrane
Database Syst Rev. 2010;(1):CD007130.
MM. Thomas RJ, King M, Lui K, et al; AACVPR; ACC; AHA; American College of Chest Physicians;
American College of Sports Medicine; American Physical Therapy Association; Canadian Association
of Cardiac Rehabilitation; European Association for Cardiovascular Prevention and Rehabilitation; InterAmerican Heart Foundation; National Association of Clinical Nurse Specialists; Preventive
Cardiovascular Nurses Association; Society of Thoracic Surgeons. AACVPR/ACC/AHA 2007
performance measures on cardiac rehabilitation for referral to and delivery of cardiac
rehabilitation/secondary prevention services endorsed by the American College of Chest Physicians,
American College of Sports Medicine, American Physical Therapy Association, Canadian Association
of Cardiac Rehabilitation, European Association for Cardiovascular Prevention and Rehabilitation, InterAmerican Heart Foundation, National Association of Clinical Nurse Specialists, Preventive
Cardiovascular Nurses Association, and the Society of Thoracic Surgeons. J Am Coll Cardiol.
2007;50(14):1400-1433.
NN.Tikkanen AU, Oyaga AR, Riano OA, et al. Paediatric cardiac rehabilitation in congenital heart disease:
A systematic review. Cardiol Young. 2012;22(3):241-250.
Page 6 of 7
Policy/Procedure Number: MCUP3128
Lead Department: Health Services
☒ External Policy
☐ Internal Policy
Next Review Date: 06/17/2016
Last Review Date: 06/17/2015
☐ Healthy Kids
☐ Employees
Policy/Procedure Title: Cardiac Rehabilitation
Original Date: 02/18/2015
Effective Date: 08/01/2015
Applies to: ☒ Medi-Cal
OO.Ueno A, Tomizawa Y. Cardiac rehabilitation and artificial heart devices. J Artif Organs. 2009;12(2):9097.
PP. Zwisler A-D, Nissen NK, Madsen M; DANREHAB Group. Cardiac rehabilitation - a health technology
assessment: Evidence from the literature and the DANREHAB trial [summary]. Copenhagen, Denmark:
Danish Centre for Evaluation and Health Technology Assessment (DACEHTA); 2006.
VIII.
DISTRIBUTION:
A. Provider Manual
IX.
POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Senior Director, Health Services
X.
REVISION DATES: 06/17/15
PREVIOUSLY APPLIED TO:
*********************************
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.
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