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 15, 2017 Next Review Date: March 2018 Policy contains: Chronic pulmonary disease. Lung transplantation. Lung volume reduction surgery. Related policies: CP# CP# CP# Noninvasive positive pressure ventilation in adults Mechanical airway clearance devices Cardiac rehabilitation ABOUT THIS POLICY: AmeriHealth Caritas Pennsylvania has developed clinical policies to assist with making coverage determinations. AmeriHealth Caritas Pennsylvania 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 AmeriHealth Caritas Pennsylvania 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. AmeriHealth Caritas Pennsylvania 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. AmeriHealth Caritas Pennsylvania s clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, AmeriHealth Caritas Pennsylvania will update its clinical policies as necessary. AmeriHealth Caritas Pennsylvania s clinical policies are not guarantees of payment. Coverage policy AmeriHealth Caritas Pennsylvania considers the use of pulmonary rehabilitation to be clinically proven and, therefore, medically necessary when both of the following criteria are met: For any of the following diagnoses: - Asthma. - Chronic obstructive pulmonary disease (COPD) spirometric grades II IV as defined by the Global Initiative for Chronic Obstructive Lung Disease (GOLD, 2017): Stage II: Forced expiratory volume in one-second/forced vital capacity (FEV 1 /FVC) < 0.7, and FEV 1 50 percent 80 percent predicted. Stage III: FEV 1 / FVC < 0.7, and FEV 1 30 percent 50 percent predicted. Stage IV: FEV 1 / FVC < 0.7, and FEV 1 < 30 percent predicted. - Bronchiectasis. - Cystic fibrosis. 1

2 - Interstitial lung disease (e.g., idiopathic pulmonary fibrosis [IPC]). - Obliterative bronchiolitis. - Restrictive respiratory disease due to a neuromuscular disorder (e.g., amyotrophic lateral sclerosis [ALS], 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). Member meets all of the following medical criteria: - Dyspnea with rest or exertion. - Limited physical activity and is unable to perform activities of daily living. - No contraindications to participating in a supervised exercise program. - Is capable of participating in the treatment plan (physically and cognitively). Limitations: All other uses of pulmonary rehabilitation are not medically necessary. Pulmonary rehabilitation for members with mild COPD (stage I) is not medically necessary due to insufficient evidence supporting its use in this population. Pulmonary rehabilitation should not be used in individuals unable to safely participate in an exercise program. Pulmonary rehabilitation services are generally provided in an outpatient setting. An individual may receive up to a lifetime maximum of 72 pulmonary rehabilitation sessions. Note: The following CPT/HCPCS codes are not listed in the Pennsylvania Medicaid fee schedule: S Pulmonary rehabilitation program, non-physician provider, per diem G Preoperative pulmonary surgery services for preparation for LVRS, complete course of services, to include a minimum of 16 days of services G Preoperative pulmonary surgery services for preparation for LVRS, 10 to 15 days of services G Preoperative pulmonary surgery services for preparation for LVRS, 1 to 9 days of services G Postdischarge pulmonary surgery services after LVRS, minimum of 6 days of services 2

3 G Postdischarge pulmonary surgery services after LVRS, minimum of 6 days of services 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, COPD is the third leading cause of death in the United States, and mortality from COPD is increasing (American Lung Association, 2017). Treatment of pulmonary diseases involves trying to arrest 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 reduction surgery by improving activity tolerance, stabilizing disease progression, and assisting in therapeutic techniques employed after surgery. Searches AmeriHealth Caritas Pennsylvania 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. The Centers for Medicare & Medicaid Services (CMS). We conducted searches on January 20, Search terms were: pulmonary rehabilitation, rehabilitation, "Rehabilitation" (MeSH) and "Lung Diseases" (MeSH). 3

4 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 AmeriHealth Caritas Pennsylvania identified several systematic reviews, guidelines developed by the American College of Chest Physicians and the American Association of Cardiovascular and Pulmonary Rehabilitation (ACCP/AACVPR, 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 stage 2 to 4 COPD 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 (HRQOL), 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 COPD. Moderate-quality evidence argues against routine use of inspiratory muscle training. There is moderate-quality evidence of effectiveness of pulmonary rehabilitation for some patients with chronic respiratory diseases other than COPD. 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 4

5 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 COPD, modifications should include treatment strategies specific to individual diseases and patients in addition to treatment strategies common to both COPD and non-copd patients. According to the ATS/ERS, pulmonary rehabilitation should be considered for any patient with chronic respiratory disease who has persistent symptoms, limited activity and/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 COPD, 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 from pulmonary rehabilitation 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 (ATS/ERS, 2006). 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 or unstable cardiac disease, may limit participation, thereby making the patient an unsuitable candidate (ATS/ERS, 2006). 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). 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. 5

6 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, AmeriHealth Caritas Pennsylvania identified three additional systematic reviews, which would not materially change the initial findings (Liu, 2014; Beauchamp, 2013; Cavalheri, 2013). In 2015, AmeriHealth Caritas Pennsylvania 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 COPD (McCarthy, 2015), interstitial lung disease (Dowman, 2014), and non-small cell lung cancer in candidates for lung resection (Crandall, 2014). In 2016, AmeriHealth Caritas Pennsylvania found one new systematic review of pulmonary rehabilitation in persons with mild COPD based on Medical Research Council dyspnea scale (mmrc) levels < 2 (Rugbjerg, 2015). Moderate-quality evidence suggested a small, significant improvement in short-term HRQOL and a clinically non-significant improvement in walking distance following pulmonary rehabilitation in patients with COPD 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 COPD 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 RCTs and higher quality cohort studies support earlier findings that pulmonary rehabilitation provides short-term improvement in exercise capacity, HRQOL, and, possibly, readmission rates in persons with stable chronic lung disease, but these improvements are not always maintained over a longer duration. 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 HRQOL offered in either home-, community-, or outpatient-based 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. Summary of clinical evidence: 6

7 Citation Lee (2016) Pulmonary rehabilitation (PR; exercise and education) or ET in adults with noncystic fibrosis bronchiectasis Moore (2016) Effect of PR on hospitalizations for Acute Exacerbations of COPD Puhan (2016) Cochrane review Effects of PR after COPD exacerbation Neves (2016) Effects of home or community-based PR (HCPR) in COPD McCarthy (2015) Content, Methods, Recommendations Systematic review of four RCTs (164 total participants) comparing PR or ET versus no treatment. Overall quality: variable risk of bias. There were significant short-term improvements in exercise capacity and HRQOL with supervised PR and ET programs, which were not always sustained in people with bronchiectasis. The frequency of exacerbations over 12 months was reduced with ET 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 PR reduces subsequent admissions for persons with acute exacerbation of COPD in the short term. This is likely due to the heterogeneous nature of individuals included in observational research and the varying standards of PR programs. Systematic review update included a total of 20 RCTs (1,477 total participants) comparing PR to usual care. Overall quality: variable risk of bias and substantial heterogeneity among study designs. High-quality evidence shows moderate to large effects of PR on HRQOL and exercise capacity in patients with COPD after an exacerbation. Some recent studies showed no benefit of PR on hospital readmissions and mortality, but results may depend on the extensiveness of PR 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 after COPD exacerbations on hospital readmissions and mortality. Systematic review and meta-analysis of 23 RCTs comparing HCPR to controls and HCPR to outpatient PR (OPR). Overall quality: moderate. Limited by insufficient power, short follow-up, and methodological rigor. Findings suggest HCPR was superior to controls based on functional capacity and dyspnea and HRQOL scores. Effects of HCPR and OPR on functional capacity or HRQOL were comparable. 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 HCPR and basic program requirements are needed. 7

8 Citation Cochrane review COPD Rugbjerg (2015) COPD with mild symptoms Crandall (2014) Lung cancer resection Dowman (2014) Content, Methods, Recommendations Systematic review and meta-analysis of 65 randomized controlled trials (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 (PR) versus usual care. PR relieves dyspnea and fatigue, improves emotional function, and enhances the sense of control that individuals have over their condition. Significant difference in treatment effect on Chronic Respiratory Questionnaire scores between hospital-based and community-based programs, but no difference between exercise-only and more complex PR programs. Future research studies should focus on identifying which components of PR are essential, its ideal length and location, the degree of supervision and intensity of training required, and how long treatment effects persist. Systematic review of four RCTs (489 participants). Overall quality: moderate. Effects of PR: - Clinically and statistically significant improvement in short-term HRQoL of 4.2 units (95% confidence interval [CI] to -3.89) on St George's Respiratory Questionnaire, but not at the longest follow-up. - Small statistically significant improvement of meters (95% CI to 35.65) in the six-minute walk test with PR, 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 PR pre- and/or postlung 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 (VO2 max < 15 ml/kg/mi) benefitted most from exercise intervention. RCTs of feasibility, acceptability, and effectiveness of specific interventions on outcomes are warranted. Cochrane review Interstitial lung disease (ILD) Systematic review of nine RCT or quasi-rct comparative studies of PR versus other or no therapy in persons with ILD. Overall quality: low to moderate due to inadequate reporting and small studies. PR appears to be safe for people with ILD. Short-term improvements in functional exercise capacity, dyspnea, and quality of life, with benefits also evident in persons with interstitial pulmonary fibrosis. Insufficient evidence to allow examination of the impact of disease severity or exercise 8

9 Citation Liu (2014) COPD Beauchamp (2013) Severe COPD Cavalheri (2013) Cochrane review Post-lung resection for non-small cell lung cancer (NSCLC) Content, Methods, Recommendations training modality or on longer-term effects of PR. Meta-analysis of 18 RCTs (n = 733) of patients with COPD 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, HRQoL scores, exercise capacity, and pulmonary functions (measured by FEV1/FVC). No statistically significant changes in maximal workload, hospital admission, cost of care, or mortality between the two groups. Authors conclusions: Home-based pulmonary rehabilitation programs represent effective therapeutic intervention approaches for relieving COPD-associated respiratory symptoms and improving HRQoL and exercise capacity. Rigorously designed, large-scale RCTs are still needed to identify an optimal standard home-based PR program. Systematic review of seven randomized controlled trials (RCTs) (619 participants) with moderate-to-severe COPD. At six-month follow-up there was a significant difference in exercise capacity in favor of 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 HRQoL. Systematic review of three RCTs (178 participants) post-lung resection for NSCLC 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 to 85.2 m). No between-group differences were observed in HRQoL 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. From the Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) GOLD website. Accessed January 20,

10 Lung Health & Diseases. How Serious Is COPD? American Lung Association website. Accessed January 20, 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. AnnIntern Med. 2011; 155(3): Ries A, Bauldoff G, Carlin B, et al. Pulmonary Rehabilitation*Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines. CHEST. May 2007; 131: 4S 42S. American College of Chest Physicians website. Accessed January 20, 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 Peer-reviewed references: Barnes, P. Medical Progress: Chronic Obstructive Pulmonary Disease. NEJM. 2000; 343: Beauchamp MK, Evans R, Janaudis-Ferreira T, Goldstein RS, Brooks D. Systematic review of supervised exercise programs after pulmonary rehabilitation in individuals with COPD. Chest Oct; 144(4): 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 Celli, B. Clinical Crossroads: A 62-Year-Old Woman with Chronic Obstructive Pulmonary Disease. JAMA. 2003; 290: 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): Dowman L, Hill CJ, Holland AE. Pulmonary rehabilitation for interstitial lung disease. Cochrane Database Syst Rev. 2014; 10: CD Ferguson, G and Cherniack, R. Current Concepts: Management of Chronic Obstructive Pulmonary Disease. NEJM. 1993; 328:

11 Lee AL, Hill CJ, McDonald CF, Holland AE. Pulmonary Rehabilitation in Individuals With Non-Cystic Fibrosis Bronchiectasis: A Systematic Review. Arch Phys Med Rehabil Jun 16. pii: S (16) doi: /j.apmr [Epub ahead of print]. 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): 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 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): 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). Epub. 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 Rugbjerg M, Iepsen UW, Jorgensen KJ, Lange P. Effectiveness of pulmonary rehabilitation in COPD with mild symptoms: a systematic review with meta-analyses. Int J Chron Obstruct Pulmon Dis. 2015; 10: Stephens, M and Yew, K. Diagnosis of Chronic Obstructive Pulmonary Disease. Am Fam Physician. 2008; 78: Sutherland, E and Cherniack, R. Management of Chronic Obstructive Pulmonary Disease. NEJM. 2004; 350: CMS National Coverage Determinations (NCDs): National Coverage Determination (NCD) for Pulmonary Rehabilitation Services (240.8). CMS website. Accessed January 20, A52696 Educational Article - Pulmonary Rehabilitation (PR) Services. CMS website. Accessed January 20,

12 A52756 Pulmonary Rehabilitation Services. CMS website. Accessed January 20, A52770 Pulmonary Rehabilitation Services. CMS website. Accessed January 20, 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 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 12

13 ICD-10 Code Description Comments 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 G0305 G0424 S9473 Description Preoperative pulmonary surgery services for preparation for 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 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 13