Clinical Policy Title: Pulmonary rehabilitation

Transcription

1 Clinical Policy Title: Pulmonary rehabilitation Clinical Policy Number: Effective Date: September 1, 2013 Initial Review Date: March 21, 2013 Most Recent Review Date: March 6, 2018 Next Review Date: March 2019 Policy contains: Chronic pulmonary or lung disease. Lung transplantation. Lung volume reduction surgery. Related policies: CP# CP# CP# CP# CP# Noninvasive positive pressure ventilation in adults Mechanical airway clearance devices Cardiac rehabilitation Lung transplants Lung volume reduction surgery ABOUT THIS POLICY: Prestige Health Choice has developed clinical policies to assist with making coverage determinations. Prestige Health Choice s clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peer-reviewed professional literature. These clinical policies along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including any state- or plan-specific definition of medically necessary, and the specific facts of the particular situation are considered by Prestige Health Choice when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. Prestige Health Choice s clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their patients. Prestige Health Choice s clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, Prestige Health Choice will update its clinical policies as necessary. Prestige Health Choice s clinical policies are not guarantees of payment. Coverage policy Prestige Health Choice considers the use of pulmonary rehabilitation to be clinically proven and, therefore, medically necessary when both criteria are met (Spruit, 2013; Qaseem, 2011; Ries, 2007 for the American College of Chest Physicians and the American Association of Cardiovascular and Pulmonary Rehabilitation [ACCP/AACVPR]): For any of the following diagnoses: - Asthma. - Chronic obstructive pulmonary disease spirometric grades 2 4, as defined by the Global Initiative for Chronic Obstructive Lung Disease (GOLD, 2018): 1

2 GOLD 2: Forced expiratory volume in one-second/forced vital capacity (FEV 1 / FVC) less than 0.7, and post-bronchodilator FEV 1 greater than or equal to 50 percent to less than 80 percent predicted. GOLD 3: FEV 1 / FVC less than 0.7, and FEV 1 greater than or equal to 30 percent to less than 50 percent predicted. GOLD 4: FEV 1 / FVC less than 0.7, and FEV 1 less than 30 percent predicted. - Bronchiectasis. - Cystic fibrosis. - Interstitial lung disease (e.g., idiopathic pulmonary fibrosis). - Obliterative bronchiolitis. - Restrictive respiratory disease due to a neuromuscular disorder (e.g., amyotrophic lateral sclerosis or Guillain-Barré). - Sarcoidosis. - Pre-and post-lung transplantation. - Pre- and post-lung volume reduction surgery. - Other documented severe pulmonary condition (e.g., lung resection for lung cancer). All of the following medical criteria: - Dyspnea with rest or exertion. - Limited physical activity and inability to perform activities of daily living. - No contraindications to participating in a supervised exercise program. - Capability to participate in the treatment plan (physically and cognitively). Limitations: Coverage determinations are subject to benefit limitations and exclusions as delineated by the state Medicaid authority. The Florida Medicaid website may be accessed at All other uses of pulmonary rehabilitation are not medically necessary. Pulmonary rehabilitation for members with mild chronic obstructive pulmonary disease (GOLD 1, defined as FEV 1 / FVC less than 0.7 and a post-bronchodilator FEV 1 greater than or equal to 80 percent predicted) is not medically necessary due to insufficient evidence supporting its use in this population (Rugbjerg, 2015). Pulmonary rehabilitation for the prevention of rehospitalizations in patients with chronic obstructive pulmonary disease who have had an exacerbation greater than four weeks after a recent hospitalization is not medically necessary due to insufficient evidence of effectiveness (Criner, 2015; Spruit, 2013). Pulmonary rehabilitation should not be used in individuals unable to safely participate in an exercise program. 2

3 Pulmonary rehabilitation services are generally provided in an outpatient setting. For Medicare members only: An individual may receive up to a lifetime maximum of 72 pulmonary rehabilitation sessions (Medicare local coverage articles A52756 and A52770). Alternative covered services: Physician services in the treatment of chronic pulmonary disease and medications as prescribed. Background Pulmonary disease is a major cause of morbidity and mortality. For example, chronic obstructive pulmonary disease is the third leading cause of death in the United States, and mortality from the disease is increasing (American Lung Association, 2017). Treatment of pulmonary diseases involves arresting the underlying pathophysiology, such as removing the offending agent (e.g., smoking cessation), and preventing and treating complications related to the lung disease (e.g., suppression of bacterial infection). Other interventions are employed to address the disability associated with pulmonary disease, one of which is pulmonary rehabilitation. The American Thoracic Society/European Respiratory Society (ATS/ERS) defines pulmonary rehabilitation as: a comprehensive intervention based on a thorough patient assessment followed by patient tailored therapies that include, but are not limited to, exercise training, education, and behavior change, designed to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long-term adherence to health-enhancing behaviors (Spruit, 2013). This definition was updated from 2006 to emphasize the importance of changing behavior, as well as stabilizing or reversing systemic manifestations of the disease. The goals of pulmonary rehabilitation are to reduce levels of morbidity and to improve activity and participation. Such programs are often started while an individual is an inpatient in a health care facility and continued in an outpatient setting. Pulmonary rehabilitation programs may also benefit individuals who are facing lung transplantation or lung volume reduction surgery by improving activity tolerance, stabilizing disease progression, and assisting in therapeutic techniques employed after surgery. Searches Prestige Health Choice searched PubMed and the databases of: UK National Health Services Centre for Reviews and Dissemination. Agency for Healthcare Research and Quality s National Guideline Clearinghouse and other evidence-based practice centers. 3

4 The Centers for Medicare & Medicaid Services (CMS). We conducted searches on January 19, Search terms were: pulmonary rehabilitation, rehabilitation, Rehabilitation (MeSH), and Lung Diseases (MeSH). We included: Systematic reviews, which pool results from multiple studies to achieve larger sample sizes and greater precision of effect estimation than in smaller primary studies. Systematic reviews use predetermined transparent methods to minimize bias, effectively treating the review as a scientific endeavor, and are thus rated highest in evidence-grading hierarchies. Guidelines based on systematic reviews. Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple cost studies), reporting both costs and outcomes sometimes referred to as efficiency studies which also rank near the top of evidence hierarchies. Findings Prestige Health Choice identified several systematic reviews, a guideline developed by the ACCP/AACVPR (Ries, 2007), and several economic studies for this policy. The success of pulmonary rehabilitation stems from its favorable influence on systemic effects and comorbidities associated with chronic lung disease. The preponderance of evidence has shown beneficial outcomes of pulmonary rehabilitation in patients primarily with GOLD 2 to 4 chronic obstructive pulmonary disease who are enrolled in hospital-based outpatient programs. There is high-quality evidence that six to 12 weeks of pulmonary rehabilitation produces benefits in several outcomes that decline gradually over 12 to 18 months, with the exception of some benefits, such as health-related quality of life, that were sustained above controls at 12 to 18 months. Other benefits include: - Symptom improvement in dyspnea (high quality). - Lower health care utilization (moderate quality). - Psychosocial benefits (moderate quality). There is low-quality, very low-quality, or insufficient evidence of effectiveness of maintenance strategies on long-term outcomes or survival or of the cost effectiveness of pulmonary rehabilitation. There is high-quality evidence of effectiveness for including unsupported endurance training of the upper extremities and strength training and exercise training of the lower extremity muscles in pulmonary rehabilitation programs. There is moderate-quality evidence of effectiveness for including education strategies (collaborative self-management and prevention and treatment of exacerbations) and noninvasive ventilation as an adjunct to exercise training in selected patients with severe chronic obstructive pulmonary disease. Moderate-quality evidence argues against routine use of inspiratory muscle training. 4

5 There is moderate-quality evidence of effectiveness of pulmonary rehabilitation for some patients with chronic respiratory diseases other than chronic obstructive pulmonary disease. There is low-quality, very low-quality, or insufficient evidence of effectiveness for including psychosocial interventions as a single therapeutic modality, supplemental oxygen during exercise training in patients with severe exercise-induced hypoxemia, and nutritional supplementation in pulmonary rehabilitation programs. Supplemental oxygen may benefit patients without exercise-induced hypoxemia to improve exercise endurance during highintensity exercise programs. For patients with chronic respiratory diseases other than chronic obstructive pulmonary disease, modifications should include treatment strategies specific to individual diseases and patients in addition to standard of care treatment strategies. According to the ATS/ERS, pulmonary rehabilitation should be considered for any patient with chronic respiratory disease who has persistent symptoms or limited activity, or is unable to adjust to illness, despite otherwise optimal medical management (Spruit, 2013). Evidence on the selection of patients who might benefit is derived mostly from patients with chronic obstructive pulmonary disease, with a growing number of studies describing rehabilitation in other chronic lung diseases (such as asthma, bronchiectasis, and cystic fibrosis) that may benefit from an in-depth pulmonary rehabilitation program. Gains can be achieved regardless of age, sex, lung function, or smoking status. Pulmonary rehabilitation is generally considered a necessary component before and after lung volume reduction surgery and lung transplantation (Spruit, 2013). The optimal candidates are clinically stable and motivated to achieve the fullest benefit from pulmonary rehabilitation. Data are limited on predictors of non-adherence, but predictors of reduced long-term adherence include social isolation and continued smoking. Patients who are hypoxemic at rest or with exercise should not be excluded from rehabilitation but should be provided with ambulatory oxygen during the exercise sessions (Spruit, 2013). Exclusion criteria include significant orthopedic or neurologic problems that reduce mobility or cooperation with physical training. In addition, poorly controlled coexisting medical conditions, especially psychiatric conditions or unstable cardiac disease, may limit participation, thereby making the patient an unsuitable candidate (Spruit, 2013). There is no consensus on the optimal number of sessions per week or the optimal duration of pulmonary rehabilitation (Spruit, 2013). Outpatient programs commonly meet two or three days per week, while inpatient programs are usually planned for five days per week. The session length per day is generally one to four hours. The evidence suggests longer programs produce greater gains and maintenance of benefits, with a minimum of eight weeks recommended to achieve a substantial effect. While programs longer than 12 weeks have produced greater sustainable benefits than shorter programs, improvement in functional exercise capacity seems to plateau within 12 weeks of the start of the pulmonary rehabilitation program, despite continued training (Spruit, 2013). 5

6 Areas in need of further research include: Optimizing the effectiveness of pulmonary rehabilitation, including defining the optimal intensity and duration of exercise training and defining the effects of the non-exercise components and the role of adjunctive therapies such as hormonal therapy, supplemental oxygen administration to non-hypoxemic patients, and non-invasive ventilation. Identifying the predictors and rationale of non-adherence and non-participation to develop effective strategies to engage participation and maintain the benefits of pulmonary rehabilitation over the long term. Expanding access to large populations of patients with chronic pulmonary diseases presently without access to pulmonary rehabilitation programs. Policy updates: In 2014, Prestige Health Choice identified three additional systematic reviews, which would not materially change the initial findings (Liu, 2014; Beauchamp, 2013; Cavalheri, 2013). In 2015, Prestige Health Choice added three new systematic reviews (McCarthy, 2015; Dowman, 2014; Crandall, 2014) and two guidelines (AHRQ, 2014; Raghu, 2011) to this policy. No economic analyses were found. Indications covered in the systematic reviews were chronic obstructive pulmonary disease (McCarthy, 2015), interstitial lung disease (Dowman, 2014), and non-small cell lung cancer in candidates for lung resection (Crandall, 2014). In 2016, Prestige Health Choice found one new systematic review of pulmonary rehabilitation in persons with mild chronic obstructive pulmonary disease based on Medical Research Council dyspnea scale (mmrc) levels less than 2 (Rugbjerg, 2015). Moderate-quality evidence suggested a small, significant improvement in short-term health-related quality of life and a clinically non-significant improvement in walking distance following pulmonary rehabilitation in patients with chronic obstructive pulmonary disease and mild symptoms. This resulted in a weak recommendation of routine pulmonary rehabilitation in these patients. In 2017, we identified four new systematic reviews and meta-analyses and no new economic studies or evidence-based guidelines for this policy. The systematic reviews and meta-analyses examined the effects of pulmonary rehabilitation in persons with chronic obstructive pulmonary disease after exacerbation (Moore, 2016; Puhan, 2016), in home- or community-based settings (Neves, 2016), and in persons with non-cystic bronchiectasis (Lee, 2016). The results from randomized controlled trials (RCTs) and higher quality cohort studies support earlier findings that pulmonary rehabilitation provides shortterm improvement in exercise capacity, health-related quality of life, and, possibly, readmission rates in persons with stable chronic lung disease, but these improvements are not always maintained over a longer duration. 6

7 Most pulmonary rehabilitation programs are offered in an outpatient setting to patients with stable chronic lung disease. Limited findings suggest that the short-term effects of pulmonary rehabilitation on functional capacity and health-related quality of life offered in either home-, community-, or outpatientbased settings are comparable. However, less is known about cost effectiveness or the optimal patient selection criteria and program components for home- or community-based settings. These results would not change earlier findings. Therefore, no changes to the policy are warranted. In 2018, we added an update of a previously included systematic review (Lee, 2016, updated 2017) and a joint guideline on prevention of acute exacerbation of chronic obstructive pulmonary disease by the ACCP and Canadian Thoracic Society (Criner, 2015). There were no changes to the systematic review findings. The guideline recommends pulmonary rehabilitation to prevent acute exacerbations in patients with moderate, severe, or very severe chronic obstructive pulmonary disease who have had a recent exacerbation within the previous four weeks, based on sufficient evidence that pulmonary rehabilitation can reduce the risk of hospitalization in this population; there was insufficient evidence to recommend pulmonary rehabilitation if the acute exacerbation occurred more than four weeks prior. This time limitation was added to the Limitations section in the policy. Summary of clinical evidence: Citation Lee (2017) Pulmonary rehabilitation in individuals with noncystic fibrosis bronchiectasis Moore (2016) Pulmonary rehabilitation as a mechanism to reduce hospitalizations for acute exacerbations of chronic obstructive pulmonary disease Puhan (2016) Content, Methods, Recommendations Systematic review of four RCTs (164 total participants) comparing pulmonary rehabilitation (exercise and education) or exercise training to no treatment. Overall quality: variable risk of bias. There were significant short-term improvements in exercise capacity and health-related quality of life with pulmonary rehabilitation or exercise training programs, which were not always sustained. The frequency of exacerbations over 12 months was reduced with exercise training only. Systematic review and meta-analysis of 10 RCTs (range 16 and 177 participants), three cohort studies (range 51 and 1,672 participants), and five before-after studies (numbers not reported). Overall quality: variable with unclear or high risk of bias. Results from RCTs, but not from cohort studies, suggest that pulmonary rehabilitation reduces subsequent admissions for persons with acute exacerbation of chronic obstructive pulmonary disease in the short term. This is likely due to the heterogeneous nature of individuals included in observational research and varying program standards. Cochrane review Pulmonary Systematic review update included a total of 20 RCTs (1,477 total participants) comparing pulmonary rehabilitation to usual care. Overall quality: variable risk of bias and substantial heterogeneity among study designs. 7

8 Citation rehabilitation following exacerbations of chronic obstructive pulmonary disease Neves (2016) Effects of home- or community-based pulmonary rehabilitation for individuals with chronic obstructive pulmonary disease McCarthy (2015) Cochrane review Effectiveness of pulmonary rehabilitation in chronic obstructive pulmonary disease with mild symptoms Rugbjerg (2015) Content, Methods, Recommendations High-quality evidence shows moderate to large effects of pulmonary rehabilitation on health-related quality of life and exercise capacity. Some recent studies showed no benefit of pulmonary rehabilitation on hospital readmissions and mortality, but results may depend on the extensiveness of these programs and study quality. Future research should investigate the impact of exercise sessions, self-management education, and other components on outcomes, and how the organization of such programs within specific health care systems determines their effects on hospital readmissions and mortality. Systematic review and meta-analysis of 23 RCTs comparing home-based pulmonary rehabilitation to controls or community-based pulmonary rehabilitation. Overall quality: moderate. Limited by insufficient power, short follow-up, and methodological rigor. Findings suggest home-based programs were superior to controls based on functional capacity and dyspnea and health-related quality of life scores and were comparable to community-based programs based on functional capacity or health-related quality of life. Improvement was greater in patients with lower FEV1. Feasibility studies are still needed to implement these programs, including their suitability in relation to different clinical needs and local contexts. Studies of cost effectiveness of home-based pulmonary rehabilitation and basic program requirements are needed. Systematic review and meta-analysis of 65 RCTs (3,822 participants). Overall quality: Lack of blinding not possible, therefore high risk of performance bias; low or unclear risk of bias in other domains with insufficient detail reported regarding allocation concealment; high attrition rates. Most programs were hospital-based (inpatient or outpatient); duration averaged eight to 12 weeks, range four to 52 weeks. Statistically and clinically significant improvement for all included outcomes of pulmonary rehabilitation versus usual care, including improvement in dyspnea and fatigue, emotional function, and sense of control that individuals have over their condition. Significant difference in treatment effect on St. George s Respiratory Questionnaire scores between hospital-based and community-based programs, but no difference between exercise-only and more complex pulmonary rehabilitation programs. Future research studies should focus on identifying which components of pulmonary rehabilitation are essential, its ideal length and location, the degree of supervision and intensity of training required, and how long treatment effects persist. Chronic obstructive pulmonary disease with mild symptoms Systematic review of four RCTs (489 participants). Overall quality: moderate. Effects of pulmonary rehabilitation: - Clinically and statistically significant improvement in short-term health-related quality of life of 4.2 units (95% confidence interval [CI] to -3.89) on St George's Respiratory Questionnaire, but not at the longest follow-up. 8

9 Citation Crandall (2014) Exercise intervention for patients surgically treated for non-small cell lung cancer Dowman (2014) Cochrane review Pulmonary rehabilitation for interstitial lung disease Liu (2014) Effectiveness of home-based pulmonary rehabilitation for patients with chronic obstructive pulmonary disease Beauchamp (2013) Content, Methods, Recommendations - Small, statistically significant improvement of meters (95% CI to 35.65) in the six-minute walk test, but not clinically relevant. No difference was found for mortality, and insufficient data prohibited meta-analysis for muscle strength and maximal exercise capacity. No adverse effects reported. Systematic review of 20 studies (eight RCTs, 12 observational) of pulmonary rehabilitation pre- and/or post-lung cancer resection. Overall quality: low due to small samples; inadequate allocation concealment; heterogeneous programs and outcomes; and a lack of clear reporting on timing, adverse events, and follow-up. Exercise intervention compared with usual care both pre- and post-surgery improved cardiopulmonary exercise capacity; increased muscle strength; and reduced fatigue, postoperative complications, and hospital length of stay. Effects on pulmonary function, quality of life and blood gas analysis were variable and inconsistent. Patients who had impaired exercise capacity at baseline (maximum O2 uptake [VO2 max] < 15 ml/kg/mi) benefited most from exercise intervention. RCTs of feasibility, acceptability, and effectiveness of specific interventions on outcomes are warranted. Systematic review of nine RCT or quasi-rct comparative studies of pulmonary rehabilitation versus other or no therapy. Overall quality: low to moderate due to inadequate reporting and small studies. Pulmonary rehabilitation appears to be safe for people with interstitial lung disease. Shortterm improvements in functional exercise capacity, dyspnea, and quality of life, with benefits also evident in persons with interstitial pulmonary fibrosis. Insufficient evidence to examine the impact of disease severity or exercise training modality or on longer-term effects. Meta-analysis of 18 RCTs (n = 733) of patients with chronic obstructive pulmonary disease who underwent 12 weeks of home-based pulmonary rehabilitation versus no intervention. Quality assessment: low to unclear risk of bias. Statistically significant improvement in dyspnea status, health-related quality of life scores, exercise capacity, and pulmonary function (measured by FEV1/FVC). No statistically significant changes in maximal workload, hospital admission, cost of care, or mortality between the two groups. Rigorously designed, large-scale RCTs are still needed to identify an optimal standard home-based pulmonary rehabilitation program. Supervised exercise programs after pulmonary rehabilitation in Systematic review of seven RCTs (619 participants) with moderate-to-severe chronic obstructive pulmonary disease. At six-month follow-up there was a significant difference in exercise capacity in favor of 9

10 Citation individuals with chronic obstructive pulmonary disease Cavalheri (2013) Content, Methods, Recommendations the post-rehabilitation interventions (standardized mean difference [SMD] -0.20; 95% CI, to -0.01), not sustained at 12 months (SMD, -0.09; 95% CI, to 0.11). No effect on health-related quality of life. Cochrane review Exercise training undertaken by people within 12 months of lung resection for nonsmall cell lung cancer Systematic review of three RCTs (178 participants) post-lung resection,with or without chemotherapy. Quality of evidence: low with high risk of bias. Exercise training was effective in increasing exercise capacity vs. control group (mean difference [MD] 50.4 m; 95% confidence interval [CI] 15.4 m to 85.2 m). No between-group differences in health-related quality of life (SMD 0.17; 95% CI to 0.49) or FEV1 (MD-0.13 L; 95% CI to 0.11 L). No differences in quadriceps force. Larger RCTs needed. References Professional society guidelines/other: Bolton CE, Bevan-Smith EF, Blakey JD, et al. British Thoracic Society guideline on pulmonary rehabilitation in adults. Thorax. 2013; 68(Suppl 2): ii1 30. DOI: /thoraxjnl Criner GJ, Bourbeau J, Diekemper RL, et al. Executive Summary. Chest. 2015; 147(4): DOI: /chest Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2018 report). Global Initiative for Chronic Obstructive Lung Disease website. Accessed January 19, Lung Health & Diseases. How Serious Is COPD? Last reviewed December 18, American Lung Association website. Accessed January 19, Qaseem A, Wilt TJ, Weinberger SE, et al. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med. 2011; 155(3): DOI: / Ries A, Bauldoff G, Carlin B, et al. Pulmonary Rehabilitation*Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines. CHEST. May 2007; 131: 4S 42S. DOI: /chest

11 Spruit MA, Singh SJ, Garvey C, et al. An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med Oct 15; 188(8): e DOI: /rccm ST. Peer-reviewed references: Beauchamp MK, Evans R, Janaudis-Ferreira T, Goldstein RS, Brooks D. Systematic review of supervised exercise programs after pulmonary rehabilitation in individuals with chronic obstructive pulmonary disease. Chest Oct; 144(4): DOI: /chest Cavalheri V, Tahirah F, Nonoyama M, Jenkins S, Hill K. Exercise training undertaken by people within 12 months of lung resection for non-small cell lung cancer. Cochrane Database Syst Rev. 2013; 7: Cd DOI: / CD pub2. Crandall K, Maguire R, Campbell A, Kearney N. Exercise intervention for patients surgically treated for Non-Small Cell Lung Cancer (NSCLC): a systematic review. Surg Oncol. 2014; 23(1): DOI: /j.suronc Dowman L, Hill CJ, Holland AE. Pulmonary rehabilitation for interstitial lung disease. Cochrane Database Syst Rev. 2014; 10: CD DOI: / CD pub3. Lee AL, Hill CJ, McDonald CF, Holland AE. Pulmonary Rehabilitation in Individuals With Non-Cystic Fibrosis Bronchiectasis: A Systematic Review. Arch Phys Med Rehabil. 2017; 98(4): e771. DOI: /j.apmr Liu XL, Tan JY, Wang T, et al. Effectiveness of home-based pulmonary rehabilitation for patients with chronic obstructive pulmonary disease: a meta-analysis of randomized controlled trials. Rehabil Nurs Jan Feb; 39(1): DOI: /rnj.112. McCarthy B, Casey D, Devane D, Murphy K, Murphy E, Lacasse Y. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2015; 2: CD DOI: / CD pub3. Moore E, Palmer T, Newson R, et al. Pulmonary Rehabilitation as a Mechanism to Reduce Hospitalizations for Acute Exacerbations of COPD: A Systematic Review and Meta-Analysis. Chest. 2016; 150(4): DOI: /j.chest Neves LF, Reis MH, Goncalves TR. Home or community-based pulmonary rehabilitation for individuals with chronic obstructive pulmonary disease: a systematic review and meta-analysis. Cad Saude Publica. 2016; 32(6). DOI: / x

12 Puhan MA, Gimeno-Santos E, Cates CJ, Troosters T. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2016; 12: Cd DOI: / CD pub4. Rugbjerg M, Iepsen UW, Jorgensen KJ, Lange P. Effectiveness of pulmonary rehabilitation in chronic obstructive pulmonary disease with mild symptoms: a systematic review with meta-analyses. Int J Chron Obstruct Pulmon Dis. 2015; 10: DOI: /copd.s CMS National Coverage Determinations (NCDs): National Coverage Determination (NCD) for Pulmonary Rehabilitation Services (240.8). CMS website. Accessed January 19, A52696 Educational Article - Pulmonary Rehabilitation (PR) Services. CMS website. Accessed January 19, A52756 Pulmonary Rehabilitation Services. CMS website. Accessed January 19, A52770 Pulmonary Rehabilitation Services. CMS website. Accessed January 19, Local Coverage Determinations (LCDs): No LCDs identified as of the writing of this policy. Commonly submitted codes Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is not an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and bill accordingly. CPT Code Description Comments N/A ICD-10 Code Description Comments D86.0 Sarcoidosis of lung D86.2 Sarcoidosis of lung with sarcoidosis of lymph nodes D86.82 Multiple cranial nerve palsies in sarcoidosis D86.85 Sarcoid myocarditis 12

13 ICD-10 Code Description Comments E84.0 Cystic fibrosis with pulmonary manifestations E84.8 Cystic fibrosis with other manifestations G12.21 Amyotrophic lateral sclerosis G61.0 Guillain-Barre syndrome J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation J44.9 Chronic obstructive pulmonary disease, unspecified J44.9 Chronic obstructive pulmonary disease, unspecified J45.20 Mild intermittent asthma, uncomplicated J45.20 Mild intermittent asthma, uncomplicated J45.21 Mild intermittent asthma with (acute) exacerbation J45.22 Mild intermittent asthma with status asthmaticus J45.30 Mild persistent asthma, uncomplicated J45.30 Mild persistent asthma, uncomplicated J45.31 Mild persistent asthma with (acute) exacerbation J45.32 Mild persistent asthma with status asthmaticus J45.40 Moderate persistent asthma, uncomplicated J45.41 Moderate persistent asthma with (acute) exacerbation J45.42 Moderate persistent asthma with status asthmaticus J45.50 Severe persistent asthma, uncomplicated J45.51 Severe persistent asthma with (acute) exacerbation J45.52 Severe persistent asthma with status asthmaticus J Unspecified asthma with (acute) exacerbation J Unspecified asthma with status asthmaticus J Unspecified asthma, uncomplicated J Exercise induced bronchospasm J Cough variant asthma J Other asthma J47.0 Bronchiectasis with acute lower respiratory infection J47.1 Bronchiectasis with (acute) exacerbation J47.9 Bronchiectasis, uncomplicated J Idiopathic pulmonary fibrosis Z48.24 Encounter for aftercare following lung transplant Z Encounter for aftercare following heart-lung transplant Z94.2 Lung transplant status Z94.3 Heart and lungs transplant status HCPCS Level II Code G0302 G0303 G0304 Description Preoperative pulmonary surgery services for preparation for lung volume reduction surgery (LVRS), complete course of services, to include a minimum of 16 days of services Preoperative pulmonary surgery services for preparation for LVRS, 10 to 15 days of services Preoperative pulmonary surgery services for preparation for LVRS, 1 to 9 days of services Comments 13

14 HCPCS Level II Code G0305 G0424 S9473 Description Post discharge pulmonary surgery services after LVRS, minimum of 6 days of services Pulmonary Rehabilitation, including exercise (includes monitoring), one hour per session, up to two sessions per day Pulmonary rehabilitation program, non-physician provider, per diem Comments 14