POLICY PRODUCT VARIATIONS DESCRIPTION/BACKGROUND RATIONALE DEFINITIONS BENEFIT VARIATIONS DISCLAIMER CODING INFORMATION REFERENCES POLICY HISTORY

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1 Original Issue Date (Created): July 1, 2002 Most Recent Review Date (Revised): January 28, 2014 Effective Date: August 20, 2014 POLICY PRODUCT VARIATIONS DESCRIPTION/BACKGROUND RATIONALE DEFINITIONS BENEFIT VARIATIONS DISCLAIMER CODING INFORMATION REFERENCES POLICY HISTORY I. POLICY Cardiac rehabilitation programs recommended by a cardiologist may be considered medically necessary for patients who require monitored exercise and have a recent history of one of the following conditions or procedures: Acute myocardial infarction (MI)(heart attack) within the preceding 12 months ; Compensated heart failure; Coronary artery bypass graft (CABG) surgery; Heart or heart-lung transplant; Heart valve surgery; Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting; Current stable angina pectoris. AND ALL of the following components must be included in the cardiac rehabilitation program: Physician-prescribed exercise each day cardiac rehabilitation services are provided; Cardiac risk factor modification; Psychosocial assessment; Outcomes assessment; and Individualized treatment plan detailing how each of the above components are utilized. A cardiac rehabilitation program should be initiated within ninety (90) days of the cardiac event and completed within six (6) months of the cardiac event. Individual consideration will be given for initiation of cardiac rehab beyond the ninety days. A comprehensive evaluation may be performed before the initiation of cardiac rehabilitation to evaluate the patient and determine an appropriate exercise program. In addition to a medical examination, an EKG stress test may be performed. Page 1

2 An additional stress test may be performed at the completion of the program. A typical program consists of an exercise and training session that lasts twenty (20) to forty (40) minutes. A reasonable duration for a cardiac rehabilitation program is twelve (12) weeks, generally three sessions per week for a total of thirty-six (36) sessions. Patients who fail to demonstrate progress as documented by the absence of improvement in exercise capacity in three (3) consecutive exercise tests, are considered to have reached their maximum potential for improvement. Services provided after a patient has reached their maximum potential for improvement are considered maintenance therapy and not considered medically necessary as part of the cardiac rehabilitation program. Repeat participation in an outpatient cardiac rehabilitation program in the absence of another qualifying cardiac event is considered investigational as there is insufficient evidence to support a conclusion concerning the health outcomes or benefits associated with this procedure. The Dr. Dean Ornish Program for Reversing Heart Disease is considered not medically necessary as an outpatient educational training program. Physical and/or occupational therapies are not considered medically necessary in conjunction with a cardiac rehabilitation program unless performed for an unrelated diagnosis. Cross-reference: None II. PRODUCT VARIATIONS TOP [N] = No product variation, policy applies as stated [Y] = Standard product coverage varies from application of this policy, see below [N] Capital Cares 4 Kids [N] PPO [N] HMO [Y] SeniorBlue HMO* [Y] SeniorBlue PPO* [N] Indemnity [N] SpecialCare [N] POS [Y] FEP PPO** *Refer to following for additional coverage indications and requirements. Page 2

3 Medicare Claims Processing Manual Publication Chapter 32 Section 140, Medicare National Coverage Determinations (NCD) Manual Publication Chapter 1, part 1 Section 20.10, Medicare Program Integrity Manual Publication Chapter 15 Section Medicare Benefit Policy Manual Publication Chapter 15 Section 232 Centers for Medicare and Medicaid (CMS) National Coverage Determination (NCD) 20.31, Intensive Cardiac Rehabilitation (ICR) Programs. Cardiac Rehabilitation sessions are limited to a maximum of 2 1-hour sessions per day for up to 36 sessions over up to 36 weeks with the option for an additional 36 sessions over an extended period of time. Intensive cardiac rehabilitation sessions are limited to 72 1-hour sessions, up to 6 sessions per day, over a period of 126 days from the date of the first session. A list of Medicare approved ICR programs is available at: **Refer to FEP Medical Policy Manual MP Cardiac Rehabilitation in the Outpatient Setting. The FEP Medical Policy manual can be found at: III. DESCRIPTION/BACKGROUND TOP Cardiac rehabilitation refers to comprehensive medically supervised programs in the outpatient setting that aim to improve the function of patients with heart disease and prevent future cardiac events. National organizations have specified core components to be included in cardiac rehabilitation programs. In 1995, the U.S. Public Health Service (USPHS) defined cardiac rehabilitation services as, in part, comprehensive, long-term programs involving medical evaluation, prescribed exercise, cardiac risk factor modification, education, and counseling. These programs are designed to limit the physiologic and psychological effects of cardiac illness, reduce the risk for sudden death or reinfarction, control cardiac symptoms, stabilize or reverse the atherosclerotic process, and enhance the psychosocial and vocational status of selected patients. This USPHS guideline recommends cardiac rehabilitation services for patients with coronary heart disease (CHD) and with heart failure, including those awaiting or following cardiac transplantation. This definition remains current as of A 2010 definition of cardiac rehabilitation by the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation is as follows: Cardiac rehabilitation can be viewed as the clinical application of preventive care by means of a professional multi-disciplinary integrated approach for comprehensive risk reduction and global long-term care of cardiac patients. Page 3

4 IV. RATIONALE TOP The policy was created with a literature review using MEDLINE and incorporated a clinical practice guideline on cardiac rehabilitation issued by the U.S. Department of Health and Human Services (HHS), issued in (1). The most recent literature search was from April 2012 through May 13, The following is a description of the key literature. Many randomized controlled trials (RCTs) have been published comparing cardiac rehabilitation to usual care for patients with established heart disease, and a number of metaanalyses of RCTs have been performed. In 2012, Oldridge identified 6 independent metaanalyses published since 2000 that reported outcomes from RCTs after cardiac rehabilitation interventions. (3) The RCTs included in the meta-analyses enrolled patients with myocardial infarction (MI), coronary heart disease (CHD), angina, percutaneous coronary intervention (PCI) and/or coronary artery bypass graft (CABG). RCTs compared cardiac rehabilitation programs (exercise only and/or comprehensive rehabilitation) to usual care. Cardiac rehabilitation was associated with a statistically significant (p<0.05) reduction in all-cause mortality in 4 of the 5 meta-analyses that reported this outcome. In addition, cardiac rehabilitation was associated with a statistically significant reduction in cardiac mortality in 3 of the 4 meta-analyses that reported disease-specific mortality as an outcome. Two of the meta-analyses on cardiac rehabilitation were conducted by the Cochrane collaboration. One of these included patients with CHD and the other focused on patients with systolic heart failure.(4, 5) Both reviews addressed exercise-based cardiac rehabilitation programs (exercise-alone or as part of comprehensive program). In 2011, Heran and colleagues identified 47 RCTs with a total of 10,794 patients comparing cardiac rehabilitation to usual care in patients with CHD. (4) Seventeen of the studies used exercise-only interventions, and 29 used comprehensive rehabilitation (i.e., exercise plus psychosocial and/or educational interventions). The majority of studies (32 of 47, 68%) were conducted in Europe. Trial sample size ranged from 28 to 2,304. The median duration of rehabilitation interventions was 3 months, and there was a median follow-up duration of 24 months. The investigators reported that most studies had limited information available on methodologic quality. Due to the nature of the intervention, patients were not blinded to treatment group in any of the studies. Only 4 studies reported that there was blinded assessment of study outcomes. In a pooled analysis of data from 17 trials reporting all-cause mortality after at least 12 months of follow-up, cardiac rehabilitation resulted in a significantly lower mortality rate compared to usual care (relative risk [RR]: 0.87, 95% confidence interval [CI]: ). Similarly, a pooled analysis of findings from 12 trials with at least 12 months followup found a significantly lower rate of cardiovascular mortality in the cardiac rehabilitation Page 4

5 compared to the usual care group (RR: 0.74, 95% CI: ). In sensitivity analyses of a priori defined variables, the investigators did not find a significant association between health outcomes and the type of cardiac rehabilitation (i.e., exercise-only versus comprehensive cardiac rehabilitation), length of the intervention or study publication date (i.e., published before 1995 or 1995 and later). The 2010 Cochrane review by Davies and colleagues identified a total of 19 trials with 3,647 heart failure patients; one large trial, HF-ACTION, contributed 2,331 (60%) patients. (5) The overall quality of the studies was judged to be poor; for example, only 3 studies adequately described their randomization process, and only 3 studies had blinded outcome assessment. A pooled analysis of the 13 studies reporting all-cause mortality with up to 12 months followup, did not find a statistically significant difference in mortality between groups (RR: 1.02, 95% CI: 0.70 to 1.51). Similarly, there was not a significant difference between groups in allcause mortality in a pooled analysis of the 4 studies reporting more than 12 months followup (RR: 0.88, 95% CI: 0.73 to 1.07). No significant between-group differences were found for the other primary outcome variable, hospital admissions. For example, when findings from 5 studies reporting hospital admissions up to 12 months were pooled, the relative risk was 0.79 (95% CI: 0.58 to 1.07). The vast majority of the studies included in the Cochrane review, including the HF-ACTION trial, were exercise-only interventions; thus, conclusions cannot be drawn from this review regarding the impact of comprehensive cardiac rehabilitation programs on mortality or hospital admissions in patients with heart failure. The Cochrane review did not require that studies only included patients with compensated heart failure. A 2011 meta-analysis by Lawler and colleagues addressed exercise-based cardiac rehabilitation programs for patients who had a recent myocardial infarction (MI). (6) To be included in the review, trials needed to include a minimum intervention duration of 2 weeks and a minimum of 12 weeks of follow-up. Interventions could involve any form of exercise program, with or without other interventions. A total of 34 RCTs with 6,111 patients met the review s inclusion criteria. In a pooled analysis of data from 18 trials, patients randomized to cardiac rehabilitation had a significantly lower risk of reinfarction than patients randomized to a control condition (odds ratio [OR]: 0.53, 95% CI: ). There was also a lower risk of all-cause mortality (OR: 0.74, 95% CI: ) and cardiovascular mortality (OR: 0.60, 95% CI: ) in the group randomized to cardiac rehabilitation compared to a control intervention. Findings of a large, multicenter RCT from the United Kingdom (U.K.) that evaluated the effectiveness of cardiac rehabilitation in a real-life setting were published by West and colleagues in (7) Called the Rehabilitation After Myocardial Infarction Trial (RAMIT), Page 5

6 the study included patients from centers with established cardiac rehabilitation programs that were multifactorial (including exercise, education and counseling), involved more than one discipline, and provided an intervention lasting a minimum of 10 hours. A total of 1,813 patients from 14 centers were randomized, 903 to cardiac rehabilitation and 910 to a control condition. Vital status was obtained at 2 years for 99.9% of participants (all but one patient) and at 7-9 years for 99.4% of participants. By 2 years, 166 patients had died, 82 (9.1%) in the cardiac rehabilitation group and 84 (9.2%) in the control group. The between-group difference in mortality at 2 years (the primary study outcome) was not statistically significant (RR: 0.98, 95% CI: 0.74 to 1.30). After 7-9 years, 488 patients had died, 245 (27%) in the cardiac rehabilitation group and 243 (26.7%) in the control group (RR: 0.99, 95% CI: ). In addition, at 2 years, cardiovascular morbidity did not differ significantly between groups. For a combined endpoint including death, non-fatal MI, stroke or revascularization, the RR was 0.96 (95% CI: ). In discussing the study s negative findings, the trial authors noted that medical management of heart disease has improved over time, and patients in the control group may have had better outcomes than in earlier RCTs on this topic. Moreover, an editorial accompanying publication of study findings emphasized that RAMIT was not an efficacy trial but instead a trial evaluating the effectiveness of actual cardiac rehabilitation programs in the U.K. (8) Finally, these results may in part reflect the degree to which clinically based cardiac rehabilitation programs in the U.K. differ from the treatment protocols used in RCTs that were based in research settings. Repeat cardiac rehabilitation No studies were identified that evaluated the effectiveness of repeat participation in a cardiac rehabilitation program. Summary Cardiac rehabilitation refers to comprehensive medically supervised programs in the outpatient setting that aim to improve the function of patients with heart disease and prevent future cardiac events. A joint national U.S. guideline has specified core components of cardiac rehabilitation programs. Numerous randomized controlled trials (RCTs) have been performed, and meta-analyses of randomized controlled trials have found that cardiac rehabilitation improves health outcomes for selected patients. The evidence is insufficient to support repeat participation in cardiac rehabilitation programs. Practice Guidelines and Position Statements In 2012, the American College of Physicians, American College of Cardiology Foundation, American Heart Association/American Association for Thoracic Surgery, Preventive Page 6

7 Cardiovascular Nurses Association and Society of Thoracic Surgeons published a joint guideline on management of stable ischemic heart disease. (9) The guideline included the following statement on cardiac rehabilitation: Medically supervised exercise programs, i.e., cardiac rehabilitation and physician-directed home-based programs, are recommended for atrisk patients at first diagnosis of stable ischemic heart disease. In 2007, the American Heart Association and American Association of Cardiovascular and Pulmonary Rehabilitation issued an updated consensus statement on the core components of cardiac rehabilitation programs. (10) The 10 core components are: patient assessment prior to beginning the program, nutritional counseling, weight management, blood pressure management, lipid management, diabetes management, tobacco cessation, psychosocial management, physical activity counseling, and exercise training. Programs that only offer supervised exercise training are not considered to be cardiac rehabilitation. The updated guidelines specify the assessment, interventions, and expected outcomes for each of the core components. For example, symptom-limited exercise testing prior to exercise training is strongly recommended. The national guideline does not specify the optimal overall length of programs or number or duration of sessions. In 2010, Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation published a position paper on cardiac rehabilitation. (2) Recommendations were based on a review of national guidelines from the U.S. and Europe. They stated that core components of cardiac rehabilitation are patient assessment, physical activity counseling, exercise training, diet/nutritional counseling, weight-control management, lipid management, blood pressure monitoring, smoking cessation, and psychosocial management. The recommended criteria for adequate exercise training are: Mode: Continuous endurance e.g., walking, jogging, cycling, swimming, etc. Duration: At least minutes (preferably minutes) Frequency: Most days (at least 3 days per week and preferably 6-7 days per week) Intensity: 50-80% of peak oxygen consumption or of peak heart rate or 40-60% of heart rate reserve. The position paper did not address repeat participation in cardiac rehabilitation programs. Page 7

8 V. DEFINITIONS TOP ANGINA PECTORIS is an oppressive pain or pressure in the chest caused by inadequate blood flow and oxygenation to heart muscle. ANGIOPLASTY is an endovascular procedure that reopens narrowed blood vessels and restores forward blood flow. CORONARY ARTERY BYPASS SURGERY is surgical establishment of a shunt that permits blood to travel from the aorta or internal mammary artery to a branch of the coronary artery at a point past an obstruction. HEART FAILURE is the inability of the heart to circulate blood effectively enough to meet the body s metabolic needs. MYOCARDIAL INFARCTION is the death of previously living heart muscle as a result of coronary artery occlusion VI. BENEFIT VARIATIONS TOP The existence of this medical policy does not mean that this service is a covered benefit under the member's contract. Benefit determinations should be based in all cases on the applicable contract language. Medical policies do not constitute a description of benefits. A member s individual or group customer benefits govern which services are covered, which are excluded, and which are subject to benefit limits and which require preauthorization. Members and providers should consult the member s benefit information or contact Capital for benefit information. VII. DISCLAIMER TOP Capital s medical policies are developed to assist in administering a member s benefits, do not constitute medical advice and are subject to change. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any medical policy related to their coverage or condition with their provider and consult their benefit information to determine if the service is covered. If there is a discrepancy between this medical policy and a member s benefit information, the benefit information will govern. Capital considers the information contained in this medical policy to be proprietary and it may only be disseminated as permitted by law. Page 8

9 VIII. CODING INFORMATION TOP Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement. Covered when medically necessary: CPT Codes Current Procedural Terminology (CPT) copyrighted by American Medical Association. All Rights Reserved. Covered when medically necessary: HCPCS Code S0340 S0341 S0342 S9472 Description LIFESTYL MOD PROG MGMT COR ART DZ; 1 QUARTER INCL ALL SUPP SRVC; 2/THIRD QUARTER/STAGE LIFESTYL MOD PROG MGMT COR ART DZ; 4 QUARTER CARDIAC REHABILITATION PROGRAM, NON-PHYSICIAN PROVIDER, PER DIEM Not medically necessary; therefore not covered: HCPCS Description Code G0422 G0423 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 ICD-9-CM Diagnosis Description Code* ACUTE MYOCARDIAL INFARCTION OLD MYOCARDIAL INFARCTION OTHER AND UNSPECIFIED ANGINA PECTORIS CONGESTIVE HEART FAILURE, UNSPECIFIED V42.1 HEART REPLACED BY TRANSPLANT V42.2 HEART VALVE REPLACED BY TRANSPLANT Page 9

10 ICD-9-CM Diagnosis Description Code* V42.9 UNSPECIFIED ORGAN OR TISSUE REPLACED BY TRANSPLANT V45.81 POSTPROCEDURAL AORTOCORONARY BYPASS STATUS V45.82 POSTPROCEDURAL PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY STATUS *If applicable, please see Medicare LCD or NCD for additional covered diagnoses. The following ICD-10 diagnosis codes will be effective October 1, 2015: ICD-10-CM Diagnosis Description Code* I20.8 Other forms of angina pectoris I20.9 Angina pectoris, unspecified I21.01 ST elevation (STEMI) myocardial infarction involving left main coronary artery I21.02 ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery I21.09 ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall I21.11 ST elevation (STEMI) myocardial infarction involving right coronary artery I21.19 ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall I21.21 ST elevation (STEMI) myocardial infarction involving left circumflex coronary artery I21.29 ST elevation (STEMI) myocardial infarction involving other sites I21.3 ST elevation (STEMI) myocardial infarction of unspecified site I21.4 Non-ST elevation (NSTEMI) myocardial infarction I22.0 Subsequent ST elevation (STEMI) myocardial infarction of anterior wall I22.1 Subsequent ST elevation (STEMI) myocardial infarction of inferior wall I22.8 Subsequent ST elevation (STEMI) myocardial infarction of other sites I22.9 Subsequent ST elevation (STEMI) myocardial infarction of unspecified site I Atherosclerotic heart disease of native coronary artery with angina pectoris with documented spasm I Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris I Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris I25.2 Old myocardial infarction I Atherosclerosis of coronary artery bypass graft(s), unspecified, with angina pectoris with documented spasm I Atherosclerosis of coronary artery bypass graft(s), unspecified, with other forms of angina pectoris I Atherosclerosis of coronary artery bypass graft(s), unspecified, with unspecified angina pectoris I Atherosclerosis of autologous vein coronary artery bypass graft(s) with angina pectoris with documented spasm I Atherosclerosis of autologous vein coronary artery bypass graft(s) with other forms of angina pectoris I Atherosclerosis of autologous vein coronary artery bypass graft(s) with unspecified angina pectoris Page 10

11 ICD-10-CM Diagnosis Description Code* I Atherosclerosis of autologous artery coronary artery bypass graft(s) with angina pectoris with documented spasm I Atherosclerosis of autologous artery coronary artery bypass graft(s) with other forms of angina pectoris I Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with other forms of angina pectoris I Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unspecified angina pectoris I Atherosclerosis of native coronary artery of transplanted heart with angina pectoris with documented spasm I Atherosclerosis of native coronary artery of transplanted heart with other forms of angina pectoris I Atherosclerosis of native coronary artery of transplanted heart with unspecified angina pectoris I Atherosclerosis of bypass graft of coronary artery of transplanted heart with angina pectoris with documented spasm I Atherosclerosis of bypass graft of coronary artery of transplanted heart with other forms of angina pectoris I Atherosclerosis of bypass graft of coronary artery of transplanted heart with unspecified angina pectoris I Atherosclerosis of other coronary artery bypass graft(s) with angina pectoris with documented spasm I Atherosclerosis of other coronary artery bypass graft(s) with other forms of angina pectoris I Atherosclerosis of other coronary artery bypass graft(s) with unspecified angina pectoris I50.9 Heart failure, unspecified Z94.1 Heart transplant status Z94.3 Heart and lungs transplant status Z94.9 Transplanted organ and tissue status, unspecified Z95.1 Presence of aortocoronary bypass graft Z95.3 Presence of xenogenic heart valve Z95.4 Presence of other heart-valve replacement Z95.5 Presence of coronary angioplasty implant and graft Z98.61 Coronary angioplasty status *If applicable, please see Medicare LCD or NCD for additional covered diagnoses. IX. REFERENCES TOP 1. Wegner NK, Froelicher ES, Smith LK. Cardiac Rehabilitation, Clinical Practice Guideline No. 17. US Dept of Health and Human Services AHCPR Publication No Corra U, Piepoli MF, Carre F et al. Secondary prevention through cardiac rehabilitation: physical activity counselling and exercise training: key components of the position paper Page 11

12 from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation. Eur Heart J 2010; 31(16): Oldridge N. Exercise-based cardiac rehabilitation in patients with coronary heart disease: meta-analysis outcomes revisited. Future Cardiol 2012; 8(5): Heran BS, Chen JM, Ebrahim S et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev 2011; (7):CD Davies EJ, Moxham T, Rees K et al. Exercise based rehabilitation for heart failure. Cochrane Database Syst Rev 2010; (4):CD Lawler PR, Filion KB, Eisenberg MJ. Efficacy of exercise-based cardiac rehabilitation post-myocardial infarction: a systematic review and meta-analysis of randomized controlled trials. Am Heart J 2011; 162(4): e2. 7. West RR, Jones DA, Henderson AH. Rehabilitation after myocardial infarction trial (RAMIT): multi-centre randomised controlled trial of comprehensive cardiac rehabilitation in patients following acute myocardial infarction. Heart 2012; 98(8): Doherty P, Lewin R. The RAMIT trial, a pragmatic RCT of cardiac rehabilitation versus usual care: what does it tell us? Heart 2012; 98(8): Qaseem A, Fihn SD, Dallas P et al. Management of stable ischemic heart disease: summary of a clinical practice guideline from the American College of Physicians/American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med 2012; 157(10): Balady GJ, Williams MA, Ades PA et al. Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation 2007; 115(20): Medicare Claims Processing Manual Publication Chapter 32. Available online at: Guidance/Guidance/Manuals/downloads//clm104c32.pdf. Accessed November 18, Medicare National Coverage Determination (NCD) for Intensive Cardiac Rehabilitation Programs (20.31). Available online at: Page 12

13 details.aspx?ncdid=339&ncdver=1&coverageselection=national&keyword=intensive +cardiac&keywordlookup=title&keywordsearchtype=and&clickon=search&bc=ga AAABAAAAAA& Accessed November 18, Medicare National Coverage Determinations (NCD) Manual Publication Chapter 1, part 1 Section [Website]: Guidance/Guidance/Manuals/Downloads/ncd103c1_Part1.pdf. Accessed July 28, Medicare Program Integrity Manual Publication Chapter 15 Section [Website]: Guidance/Guidance/Manuals/Downloads/pim83c15.pdf. Accessed July 28, Medicare Benefit Policy Manual Publication Chapter 15 Section 232 [Website]: Guidance/Guidance/Manuals/Downloads/bp102c15.pdf. Accessed July 28, 2014 X. POLICY HISTORY TOP MP CAC 4/27/04 CAC 9/28/04 CAC 9/13/05 CAC 7/25/06 CAC 6/26/07 CAC 5/27/08 CAC 3/31/09 Consensus CAC 3/30/10 Consensus CAC 11/30/10 Adopted BCBSA medically necessary criteria. Added additional medical necessity indication for heart-lung transplant. Added investigational statement for repeat cardiac rehabilitation. Revised Medicare variation due to new NCD and LCD. CAC 4/24/12 Consensus review; no changes, references updated. CAC 3/26/13 Consensus, no change to policy statement, references updated. Background Description updated. FEP variation added to reference to the manual MP Cardiac Rehabilitation in the Outpatient Setting. Codes reviewed. Admin update 1/2014 removed Novitas Solutions Local Coverage Determination (LCD) L31481, Cardiac Rehabilitation Program Services retired CAC 1/28/14 Consensus. No change to policy statements. References updated. Added rationale section. Added reference to Medicare benefit manual Chapter 32. Page 13

14 Adminstrative change Added the following references to the Medicare variation Medicare National Coverage Determinations (NCD) Manual Publication Chapter 1, part 1 Section 20.10, Medicare Program Integrity Manual Publication Chapter 15 Section Medicare Benefit Policy Manual Publication Chapter 15 Section 232 Top Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company, Capital Advantage Assurance Company and Keystone Health Plan Central. Independent licensees of the BlueCross BlueShield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. Page 14