CARDIAC REHABILITATION (PHASE II)

Protocol: CAR032
Effective Date: May 9, 2011
Table of Contents

Page

COMMERCIAL, MEDICARE & MEDICAID COVERAGE RATIONALE......................................... 1

BACKGROUND ...................................................................................................................................... 2
CLINICAL EVIDENCE........................................................................................................................... 3
APPLICABLE CODES ............................................................................................................................ 4
REFERENCES ......................................................................................................................................... 5
PROTOCOL HISTORY/REVISION INFORMATION .......................................................................... 8
INSTRUCTIONS FOR USE
This protocol provides assistance in interpreting UnitedHealthcare benefit plans. When deciding
coverage, the enrollee specific document must be referenced. The terms of an enrollee's document
(e.g., Certificate of Coverage (COC) or Evidence of Coverage (EOC)) may differ greatly. In the event
of a conflict, the enrollee's specific benefit document supersedes this protocol. All reviewers must first
identify enrollee eligibility, any federal or state regulatory requirements and the plan benefit coverage
prior to use of this Protocol. Other Protocols, Policies and Coverage Determination Guidelines may
apply. UnitedHealthcare reserves the right, in its sole discretion, to modify its Protocols, Policies and
Guidelines as necessary. This protocol is provided for informational purposes. It does not constitute
medical advice.

COMMERCIAL, MEDICARE & MEDICAID COVERAGE RATIONALE

Commercial coverage rationale will follow that of Medicare.
The Medicare National Coverage Determination for Cardiac Rehabilitation was repealed February 22,
2010 and we are referred to the following for reference. There is no Local Coverage Determination for
Nevada for Cardiac Rehabilitation Programs.
The current coverage for cardiac rehabilitation programs as listed in the Medicare Claims Processing
Manual, Chapter 32 Billing Requirements for Special Services state:
140.2 Cardiac Rehabilitation Program Services Furnished On or After January 1, 2010
Medicare covers cardiac rehabilitation items and services for patients who have experienced one or
more of the following:

An acute myocardial infarction within the preceding 12 months; or

A coronary artery bypass surgery; or
Current stable angina pectoris; or
Heart valve repair or replacement; or

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Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting; or

A heart or heart-lung transplant.

Cardiac rehabilitation programs must include the following components:

Physician-prescribed exercise each day cardiac rehabilitation items and services are furnished;
Cardiac risk factor modification, including education, counseling, and behavioral intervention
at least once during the program, tailored to patients individual needs;
Psychosocial assessment;
Outcomes assessment; and
An individualized treatment plan detailing how components are utilized for each patient.
Cardiac rehabilitation items and services must be furnished in a physicians office or a hospital
outpatient setting. All settings must have a physician immediately available and accessible for medical
consultations and emergencies at all time items and services are being furnished under the program.
This provision is satisfied if the physician meets the requirements for the direct supervision of
physicians office services as specified at 42 CFR 410.26 and for hospital outpatient therapeutic
services as specified at 42 CFR 410.27.
For Medicare and Medicaid Determinations Related to States Outside of Nevada:
Please review Local Coverage Determinations that apply to other states outside of Nevada.
http://www.cms.hhs.gov/mcd/search
Important Note: Please also review local carrier Web sites in addition to the Medicare Coverage
database on the Centers for Medicare and Medicaid Services Website.

BACKGROUND
Phase II cardiac rehabilitation, is a comprehensive, long-term program including medical evaluation,
prescribed exercise, cardiac risk factor modification, education, and counseling. Phase II refers to
outpatient, medically supervised programs that are typically initiated 1 to 3 weeks after hospital
discharge and provide appropriate electrocardiographic monitoring. Underlying conditions may
include recent myocardial infarction, heart transplant, valve surgery, or revascularization. It may also
be helpful for patients with heart failure with or without left ventricular assist devices or for patients
with angina. Cardiac rehabilitation combines exercise training with counseling about improving
modifiable coronary risk factors. Electrocardiographic (ECG) monitoring during therapy may or may
not be required. Cardiac rehabilitation provided in the outpatient setting is one potential component of
the continuum of care, at times preceded by inpatient rehabilitation or followed by self-management
and ongoing exercise. Rehabilitation programs for cardiac transplant patients must take into account
the denervated state. Patients with significant valvular dysfunction are at greater risk for ventricular
fibrillation and tachyarrhythmias as well as exertional syncope.
Contraindications for entry into a comprehensive program include unstable cardiac conditions (e.g.,
uncontrolled arrhythmias, critical aortic stenosis, unstable angina, pericarditis), active infection (e.g.,

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endocarditis, fever), recent venous thromboembolism, uncontrolled hypertension, or a severe

orthopedic condition that would prohibit exercise.
Baseline assessment prior to admission into a cardiac rehabilitation program includes history and
physical examination, review of medications, lipid testing, resting 12 lead ECG, and exercise stress
testing. Exercise prescription is based on the results of the monitored exercise test; goals may be based
on heart rate, rating of perceived exertion (RPE), or metabolic equivalent units (METs). The exercise
component typically includes both aerobic activities and strength training.

CLINICAL EVIDENCE
Meta-analysis of clinical trials of cardiac rehabilitation and other studies for patients with cardiac
compromise have demonstrated statistically significant reduction in cardiovascular death, improved
health-related quality of life, improved exercise capacity, improved functional capacity, but no
reduction in recurrent myocardial infarction or revascularization. A retrospective analysis of 1579
subjects who had undergone cardiac bypass concluded that exercise training in supervised cardiac
rehabilitation programs significantly improved exercise capacity, measures of chronotropic dynamics,
and prognostic risk scores, which translate into a decrease in predicted mortality. Patients with
coronary artery disease who did not receive exercise therapy after hospitalization were found to decline
in physical activity level. Exercise training is recommended for patients with chronic atrial fibrillation
or heart failure who are stable; it results in decreased mortality and hospitalizations, and in improved
quality of life. In a retrospective chart review of 235 consecutive obese patients with coronary heart
disease, cardiac rehabilitation reduced overall risk and improved health-related quality of life. It is
proposed that, with the use of a ventricular assist device as a bridge to transplant, there is an
opportunity to improve patient fitness level prior to transplant.
The exercise component of cardiac rehabilitation typically includes both aerobic activities and strength
training. Studies compared aerobic exercise alone versus aerobic exercise and strength training and
found that the addition of the strength training resulted in greater improvements at follow-up. A metaanalysis found that aerobic training alone reversed remodeling for stable left ventricular heart failure
patients; authors were unable to confirm this effect for the combination of aerobic training and
strengthening. A group-based aerobic interval training program improved functional capacity and the
quality of life in patients with heart failure. A randomized controlled trial that included 67
hypercholesterolemic men concluded that 12 weeks of moderate intensity walking was sufficient to
improve the ratio of total cholesterol to HDL cholesterol. Long-term aerobic exercise training is
effective in improving respiratory efficiency, increasing left ventricular systolic function, attenuating
negative remodeling, and stopping further progression in patients with coronary heart disease and
chronic heart failure after successful percutaneous coronary intervention. Studies have shown benefits
with protocols that vary in duration, intensity, and modalities across a variety of cardiac disorders. One
study that addressed long-term outcomes after cardiac rehabilitation showed additional benefit to
ongoing patient monitoring and counseling over a 4-year period for those with ischemic heart disease.
ECG monitoring was not consistent across studies and was not a variable that was considered related to
outcomes, but it may be appropriate as one component of supervision. It is used initially for all patients
and subsequently as an adjunct for more significantly impaired patients based on the results of

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monitored exercise testing and clinical symptoms. Other components of supervision may include
intermittent or continuous monitoring of heart rate, blood pressure, and RPE. American Association of
Cardiovascular and Pulmonary Rehabilitation guidelines classify patients into high-risk, moderate-risk,
and low-risk for exercise participation, and recommend graded supervision and monitoring based on
risk.
Education components may include information about medication management, lipid management,
diet, exercise, smoking cessation, and the disease process. One study compared video education in
addition to typical education for self-care and symptom management with typical care alone and found
improved self-care with the addition of the video education. Another study noted improvement in
adherence with telephone support as compared with no support. One program compared exercise and
support with a comprehensive program and found no difference. One study compared a home-based
program to no program and determined a decrease in hospitalizations with a home-based program. A
study showed that attitudes, self-efficacy, and cognition play a critical role in self management for
heart failure subjects. Self-management, adherence, and long-term adherence to any behavioral change
remain a challenge for many, and there is little research to support one method of support, follow-up,
and reinforcement over others.
Inappropriate Indications
Contraindications for entry into a comprehensive program include unstable cardiac conditions (e.g.,
uncontrolled arrhythmias, critical aortic stenosis, unstable angina, pericarditis), active infection (e.g.,
endocarditis, fever), recent venous thromboembolism, uncontrolled hypertension, a severe orthopedic
condition that would prohibit exercise, uncompensated heart failure, or for those post heart transplant,
an acute rejection episode.
All clinical evidence was obtained from Milliman Care Guidelines, 14th edition, Cardiac Rehabilitation
and was accessed March 2011.
APPLICABLE CODES
The codes listed in this policy are for reference purposes only. Listing of a service or device code in
this policy does not imply that the service described by this code is a covered or non-covered health
service. Coverage is determined by the benefit document. This list of codes may not be all inclusive.
CPT Code
93797
93798

Description
Physician services for outpatient cardiac rehabilitation without continuous
ECG monitoring (per session)
Physician services for outpatient cardiac rehabilitation with continuous ECG
monitoring (per session)

CPT is a registered trademark of the American Medical Association.

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HCPCS Code
G0422
G0423
S9472

Description
Intensive cardiac rehabilitation; with or without continuous ECG monitoring
with exercise, per session.
Intensive cardiac rehabilitation; with or without continuous ECG monitoring
without exercise, per session
Cardiac rehabilitation program, non-physician, per diem

Effective for dates of service on or after January 1, 2010, hospitals and practitioners may report a
maximum of 2 1-hour sessions per day. In order to report one session of cardiac rehabilitation services
in a day, the duration of treatment must be at least 31 minutes. Two sessions of cardiac rehabilitation
services may only be reported in the same day if the duration of treatment is at least 91 minutes. In
other words, the first session would account for 60 minutes and the second session would account for
at least 31 minutes if two sessions are reported. If several shorter periods of cardiac rehabilitation
services are furnished on a given day, the minutes of service during those periods must be added
together for reporting in 1-hour session increments.
Example: If the patient receives 20 minutes of cardiac rehabilitation services in the day, no cardiac
rehabilitation session may be reported because less than 31 minutes of services were furnished.
Example: If a patient receives 20 minutes of cardiac rehabilitation services in the morning and 35
minutes of cardiac rehabilitation services in the afternoon of a single day, the hospital or practitioner
would report 1 session of cardiac rehabilitation services under 1 unit of the appropriate CPT code for
the total duration of 55 minutes of cardiac rehabilitation services on that day.
Example: If the patient receives 70 minutes of cardiac rehabilitation services in the morning and 25
minutes of cardiac rehabilitation services in the afternoon of a single day, the hospital or practitioner
would report two sessions of cardiac rehabilitation services under the appropriate CPT code(s) because
the total duration of cardiac rehabilitation services on that day of 95 minutes exceeds 90 minutes.
Example: If the patient receives 70 minutes of cardiac rehabilitation services in the morning and 85
minutes of cardiac rehabilitation services in the afternoon of a single day, the hospital or practitioner
would report two sessions of cardiac rehabilitation services under the appropriate CPT code(s) for the
total duration of cardiac rehabilitation services of 155 minutes. A maximum of two sessions per day
may be reported, regardless of the total duration of cardiac rehabilitation services.

REFERENCES
Arnold JM, et al. Canadian Cardiovascular Society consensus conference recommendations on heart
failure 2006: diagnosis and management. Canadian Journal of Cardiology 2006;22(1):23-45.
Wise FM. Exercise based cardiac rehabilitation in chronic heart failure. Australian Family Physician
2007;36(12):1019-24.

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Myers J. Principles of exercise prescription for patients with chronic heart failure. Heart Failure
Reviews 2008;13(1):61-8. DOI: 10.1007/s10741-007-9051-0.
Franklin BA, de Jong, AT. Exercise prescription. In: AACVPR Cardiac Rehabilitation Resource
Manual. Champaign, IL: Human Kinetics; 2006:75-87
Kavanagh T. Cardiac transplantation. In: AACVPR Cardiac Rehabilitation Resource Manual.
Champaign, IL: Human Kinetics; 2006:149-54.
Tabet JY, et al. Determination of exercise training level in coronary artery disease patients on beta
blockers. European Journal of Cardiovascular Prevention and Rehabilitation 2008;15(1):67-72. DOI:
10.1097/HJR.0b013e3282eff61f.
Squires RW, Hamm LF. Exercise and the coronary heart disease connection. In: AACVPR Cardiac
Rehabilitation Resource Manual. Champaign, IL: Human Kinetics; 2006:53-62
Puetz TW, Beasman KM, O'Connor PJ. The effect of cardiac rehabilitation exercise programs on
feelings of energy and fatigue: a meta-analysis of research from 1945 to 2005. European Journal of
Cardiovascular Prevention and Rehabilitation 2006;13(6):886-93. DOI:
10.1097/01.hjr.0000230102.55653.0b.
Adams BJ, Carr JG, Ozonoff A, Lauer MS, Balady GJ. Effect of exercise training in supervised
cardiac rehabilitation programs on prognostic variables from the exercise tolerance test. American
Journal of Cardiology 2008;101(10):1403-7. DOI: 10.1016/j.amjcard.2008.01.016.
Reid RD, et al. Determinants of physical activity after hospitalization for coronary artery disease: the
Tracking Exercise After Cardiac Hospitalization (TEACH) Study. European Journal of Cardiovascular
Prevention and Rehabilitation 2006;13(4):529-37. DOI: 10.1097/01.hjr.0000201513.13343.97
Hegbom F, Stavem K, Sire S, Heldal M, Orning OM, Gjesdal K. Effects of short-term exercise training
on symptoms and quality of life in patients with chronic atrial fibrillation. International Journal of
Cardiology 2007;116(1):86-92. DOI: 10.1016/j.ijcard.2006.03.034.
Myers J, et al. Effects of exercise training on heart rate recovery in patients with chronic heart failure.
American Heart Journal 2007;153(6):1056-63. DOI: 10.1016/j.ahj.2007.02.038.
McKelvie RS. Exercise training in patients with heart failure: clinical outcomes, safety, and
indications. Heart Failure Reviews 2008;13(1):3-11. DOI: 10.1007/s10741-007-9052-z.
Lavie CJ, Morshedi-Meibodi A, Milani RV. Impact of cardiac rehabilitation on coronary risk factors,
inflammation, and the metabolic syndrome in obese coronary patients. Journal of the Cardiometabolic
Syndrome 2008;3(3):136-40. DOI: 10.1111/j.1559-4572.2008.00002.x.
Beckers PJ, Denollet J, Possemiers NM, Wuyts FL, Vrints CJ, Conraads VM. Combined enduranceresistance training vs. endurance training in patients with chronic heart failure: a prospective
randomized study. European Heart Journal 2008;29(15):1858-66. DOI: 10.1093/eurheartj/ehn222.

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Arthur HM, et al. Effect of aerobic vs combined aerobic-strength training on 1-year, post-cardiac
rehabilitation outcomes in women after a cardiac event. Journal of Rehabilitation Medicine
2007;39(9):730-5. DOI: 10.2340/16501977-0122.
Haykowsky MJ, Liang Y, Pechter D, Jones LW, McAlister FA, Clark AM. A meta-analysis of the
effect of exercise training on left ventricular remodeling in heart failure patients: the benefit depends
on the type of training performed. Journal of the American College of Cardiology 2007;49(24):232936. DOI: 10.1016/j.jacc.2007.02.055.
Nilsson BB, Westheim A, Risberg MA. Long-term effects of a group-based high-intensity aerobic
interval-training program in patients with chronic heart failure. American Journal of Cardiology
2008;102(9):1220-4. DOI: 10.1016/j.amjcard.2008.06.046.
Coghill N, Cooper AR. The effect of a home-based walking program on risk factors for coronary heart
disease in hypercholesterolaemic men. A randomized controlled trial. Preventive Medicine
2008;46(6):545-51. DOI: 10.1016/j.ypmed.2008.01.002.
Vasiliauskas D, et al. Exercise training after coronary angioplasty improves cardiorespiratory function.
Scandinavian Cardiovascular Journal 2007;41(3):142-8. DOI: 10.1080/14017430601187116.
Lear SA, et al. The Extensive Lifestyle Management Intervention (ELMI) after cardiac rehabilitation: a
4-year randomized controlled trial. American Heart Journal 2006;152(2):333-9. DOI:
10.1016/j.ahj.2005.12.023.
Albert NM, Buchsbaum R, Li J. Randomized study of the effect of video education on heart failure
healthcare utilization, symptoms, and self-care behaviors. Patient Education and Counseling
2007;69(1-3):129-39. DOI: 10.1016/j.pec.2007.08.007.
Shearer NB, Cisar N, Greenberg EA. A telephone-delivered empowerment intervention with patients
diagnosed with heart failure. Heart and Lung 2007;36(3):159-69. DOI: 10.1016/j.hrtlng.2006.08.006.
Brugemann J, Poels BJ, Oosterwijk MH, van der Schans CP, Postema K, van Veldhuisen DJ. A
randomised controlled trial of cardiac rehabilitation after revascularisation. International Journal of
Cardiology 2007;119(1):59-64. DOI: 10.1016/j.ijcard.2006.07.047.
Dracup K, et al. Effects of a home-based exercise program on clinical outcomes in heart failure.
American Heart Journal 2007;154(5):877-83. DOI: 10.1016/j.ahj.2007.07.019.
Dickson VV, Deatrick JA, Riegel B. A typology of heart failure self-care management in non-elders.
European Journal of Cardiovascular Nursing 2008;7(3):171-81. DOI: 10.1016/j.ejcnurse.2007.11.005.
Barbour KA, Miller NH. Adherence to exercise training in heart failure: a review. Heart Failure
Reviews 2008;13(1):81-9. DOI: 10.1007/s10741-007-9054-x.

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Kline KS, Scott LD, Britton AS. The Use of Supportive-Educative and Mutual Goal-Setting Strategies
to Improve Self-Management for Patients With Heart Failure. Home Healthcare Nurse
2007;25(8):502-510. DOI: 10.1097/01.NHH.0000289104.60043.7d.
Kavanagh T. Chronic heart failure. In: AACVPR Cardiac Rehabilitation Resource Manual.
Champaign, IL: Human Kinetics; 2006:141-8.

PROTOCOL HISTORY/REVISION INFORMATION

Date
03/24/2011
12/23/2010

Action/Description
Corporate Medical Affairs Committee

The foregoing Health Plan of Nevada/Sierra Health & Life Health Operations protocol has been
adopted from an existing UnitedHealthcare coverage determination guideline that was researched,
developed and approved by the UnitedHealthcare Coverage Determination Committee.

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