Coverage Policy Manual
Policy #: 1997151
Category: Rehabilitation
Initiated: September 1997
Last Review: May 2023
  Cardiac Rehabilitation

Description:
Heart disease is the leading cause of mortality in the United States, accounting for more than half of all deaths. Coronary artery disease is the most common cause of heart disease. In a 2023 update on heart disease and stroke statistics from the American Heart Association, it was estimated that 720,000 Americans have a new coronary attack (first hospitalized myocardial infarction or coronary heart disease death) and 335,000 have a recurrent attack annually (Tsao, 2023). Both coronary artery disease and various other disorders—structural heart disease and other genetic, metabolic, endocrine, toxic, inflammatory, and infectious causes—can lead to the clinical syndrome of heart failure, of which there are about 650,000 new cases in the United States annually (Balady, 2007). Given the burden of heart disease, preventing secondary cardiac events and treating the symptoms of heart disease and heart failure have received much attention from national organizations.
 
In 1995, the U.S. Public Health Service 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.” The U.S. Public Health Service recommended cardiac rehabilitation services for patients with coronary heart disease and with heart failure, including those awaiting or following cardiac transplantation. A 2010 definition of cardiac rehabilitation from the European Association of Cardiovascular Prevention and Rehabilitation stated: “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” (Corra, 2010). Since the 1995 release of the U.S. Public Health Service guidelines, other societies, including in 2005 the American Heart Association and in 2010 the Heart Failure Society of America have developed guidelines on the role of cardiac rehabilitation in patient care (Leon, 2005; Lindenfeld, 2010).
 
The goal of such programs is to reduce the morbidity and mortality associated with cardiovascular disease. The scientific literature documents that some of the benefits of participation in a cardiac rehabilitation program include improvement in exercise tolerance, blood lipid levels, and psychosocial well-being, as well as a reduction in cigarette smoking and stress. Meta-analysis of data from randomized controlled studies indicates a reduction in mortality in patients participating in cardiac rehabilitation following myocardial infarction.
 
Under clinically controlled conditions the cardiac patient improves physical endurance and stamina through participation in an individualized exercise regimen. Behavioral interactions, an integral component of a comprehensive rehabilitation program, are designed to educate and motivate the patients to adopt long-term lifestyle changes that help to reduce cardiovascular risk factors amenable to patient control, e.g., diet, smoking, stress management.
 
Coding
Outpatient Cardiac Rehab services should be reported using CPT codes 93797 or 93798. The HCPCS codes G0422 and G0423 describe a frequency greater than the policy allows and therefore, will not be covered for cardiac rehabilitation services.

Policy/
Coverage:
Effective July 2023
 
For some contracts, this service is a contract specific benefit. Additional restrictions may apply to members with contracts with limitations or exclusions for cardiac rehabilitation therapy.
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
Cardiac Rehabilitation Programs meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness and are covered when:
 
    • The program is provided in either the outpatient department of a hospital or in a physician directed clinic;
    • The physician is on the premises available to perform medical duties at all times the facility is open and each patient is under the care of a hospital or clinic physician;
    • The facility has available for immediate use all the necessary cardio-pulmonary emergency diagnostic and therapeutic life saving equipment accepted by the medical community as medically necessary, e.g., oxygen, cardiopulmonary resuscitation equipment, or defibrillator;
    • The program is conducted in an area set aside for the exclusive use of the program while it is in session;
    • The program is staffed by personnel necessary to conduct the program safely and effectively, who are trained in both basic and advanced life support techniques and in exercise therapy for coronary disease. Services of non-physician personnel must be furnished under the direct supervision of a physician. Direct supervision means that a physician must be in the exercise program area. It does not mean the physician must physically be present in the exercise room itself but must be immediately available and accessible for an emergency at all times;
    • The non physician personnel are employees of the physician, hospital, or clinic conducting the program and their services are incident to a physician's professional services.
 
Cardiac Rehabilitation Programs meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness and are eligible for coverage for Individuals who:
 
    • Have a clear clinical need for this type of program and are referred by their physician for participation in the program; and
    • Have one of the following in the 12 months prior to the initiation of the Cardiac Rehab program:
 
        • History of acute myocardial infarction;
        • Coronary artery bypass, PTCA, or other types of percutaneous therapeutic coronary artery intervention, such as atherectomy, stent placement, etc.;
        • Repair or replacement of heart valve;
        • Heart transplant or heart/lung transplant;
        • Stable angina pectoris;
        • Class III or IV CHF;
        • Sustained ventricular tachycardia or fibrillation; or
        • Survivor following cardiac arrest.
 
Cardiac Rehabilitation programs meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness and are eligible for coverage when rendered at a frequency of three sessions per week up to a duration of twelve weeks (36 sessions).
 
Outpatient Cardiac Rehab services should be reported using CPT codes 93797 or 93798.
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
Uses of cardiac rehabilitation programs not listed above as covered do not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes.
 
For contracts without primary coverage criteria, uses of cardiac rehabilitation programs not listed above as covered are considered investigational. Investigational services are an exclusion in the member certificate of coverage.
 
Repeat participation in an outpatient cardiac rehabilitation program in the absence of another qualifying cardiac event does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes.
 
For contracts without primary coverage criteria  repeat participation in an outpatient cardiac rehabilitation program in the absence of another qualifying cardiac event is considered investigational. Investigational services are an exclusion in the member certificate of coverage.
 
Intensive cardiac rehabilitation with the Ornish Program for Reversing Heart Disease, Pritikin Program, or Benson-Henry Institute Program does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes.
 
For contracts without primary coverage criteria, intensive cardiac rehabilitation with the Ornish Program for Reversing Heart Disease, Pritikin Program, or Benson-Henry Institute Program is considered investigational. Investigational services are an exclusion in the member certificate of coverage.
 
Virtual cardiac rehabilitation does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes.
 
For contracts without primary coverage criteria, virtual cardiac rehabilitation is considered investigational. Investigational services are an exclusion in the member certificate of coverage.
 
HCPCS codes G0422 and G0423 describe a frequency greater than the policy allows.  These services do not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes and are not covered.
 
For members with contracts without primary coverage criteria, services described by G0422 and G0423 are considered not medically necessary. Services that are not medically necessary are specific contract exclusions in most member benefit certificates of coverage.
 
Psychotherapy/Psychological Testing as a routine part of the evaluation or treatment of a candidate for a Cardiac Rehabilitation Program does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes.
 
For members with contracts without primary coverage criteria, Psychotherapy/Psychological Testing as a routine part of the evaluation or treatment of a candidate for a Cardiac Rehabilitation Program is considered not medically necessary. Services that are not medically necessary are specific contract exclusions in most member benefit certificates of coverage.
 
Note: These services may be covered if the patient has a diagnosed mental, psychoneurotic, or personality disorder and/or exhibits symptoms of a severity that warrant evaluation and/or therapy.
 
Physical and Occupational Therapy services as a routine part of a Cardiac Rehabilitation Program does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes and is not covered.
 
For members with contracts without primary coverage criteria, Physical and Occupational Therapy services as a routine part of a Cardiac Rehabilitation Program is considered not medically necessary. Services that are not medically necessary are specific contract exclusions in most member benefit certificates of coverage.
 
Note: These services may be covered if the patient has a non-cardiac condition for which physical and/or occupational therapy are considered medically necessary.
 
Note:
    • Patient Education is not covered as a separately identifiable service when rendered as part of a Cardiac Rehabilitation Program.
    • Room and Board furnished to Individuals or family members by some free-standing facilities is not covered.
 
Effective November 2014 through June 2023
 
For some contracts, this service is a contract specific benefit. Additional restrictions may apply to members with contracts with limitations or exclusions for cardiac rehabilitation therapy.
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
Cardiac Rehabilitation Programs meet primary coverage criteria for effectiveness and are covered when:
    • The program is provided in either the outpatient department of a hospital or in a physician directed clinic;
    • The physician is on the premises available to perform medical duties at all times the facility is open and each patient is under the care of a hospital or clinic physician;
    • The facility has available for immediate use all the necessary cardio-pulmonary emergency diagnostic and therapeutic life saving equipment accepted by the medical community as medically necessary, e.g., oxygen, cardiopulmonary resuscitation equipment, or defibrillator;
    • The program is conducted in an area set aside for the exclusive use of the program while it is in session;
    • The program is staffed by personnel necessary to conduct the program safely and effectively, who are trained in both basic and advanced life support techniques and in exercise therapy for coronary disease. Services of non-physician personnel must be furnished under the direct supervision of a physician. Direct supervision means that a physician must be in the exercise program area. It does not mean the physician must physically be present in the exercise room itself but must be immediately available and accessible for an emergency at all times;
    • The non physician personnel are employees of the physician, hospital, or clinic conducting the program and their services are incident to a physician's professional services.
 
Cardiac Rehabilitation Programs meet primary coverage criteria for effectiveness and are eligible for coverage for patients who:
    • Have a clear clinical need for this type of program and are referred by their physician for participation in the program; and
    • Have one of the following in the 12 months prior to the initiation of the Cardiac Rehab program:
        • Stable angina pectoris;
        • History of acute myocardial infarction;
        • Coronary artery bypass, PTCA, or other types of percutaneous therapeutic coronary artery intervention, such as atherectomy, stent placement, etc.;
        • Heart transplant or heart/lung transplant;
        • Repair or replacement of heart valve;
        • Class III or IV CHF;
        • Sustained ventricular tachycardia or fibrillation; or
        • Survivor following cardiac arrest.
 
Cardiac Rehabilitation programs meet primary coverage criteria for effectiveness and are eligible for coverage when rendered at a frequency of three sessions per week up to a duration of twelve weeks (36 sessions).
 
Outpatient Cardiac Rehab services should be reported using CPT codes 93797 or 93798.
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
Psychotherapy/Psychological Testing is not covered as a routine part of the evaluation or treatment of a candidate for a Cardiac Rehabilitation Program.
 
*Note: These services may be covered if the patient has a diagnosed mental, psychoneurotic, or personality disorder and/or exhibits symptoms of a severity that warrant evaluation and/or therapy.
 
Physical and Occupational Therapy services are not covered as a routine part of a Cardiac Rehabilitation Program.
 
*Note: These services may be covered if the patient has a non-cardiac condition for which physical and/or occupational therapy are considered medically necessary.
 
Patient Education is not covered as a separately identifiable service when rendered as part of a Cardiac Rehabilitation Program.
 
Room and Board furnished to patients or family members by some free-standing facilities is not covered.
 
Other uses of cardiac rehabilitation does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness.
 
For contracts without primary coverage criteria, other uses of cardiac rehabilitation is considered investigational. Investigational services are an exclusion in the member certificate of coverage.
 
HCPCS codes G0422 and G0423 describe a frequency greater than the policy allows.  These services do not meet primary coverage criteria and are not covered. For members with contracts without primary coverage criteria, services described by G0422 and G0423 are considered not medically necessary. Services that are not medically necessary are specific contract exclusions in most member benefit certificates.
 
Effective Prior to November 2014
 
Cardiac Rehabilitation Programs meet primary coverage criteria for effectiveness and are covered when:
    • The program is provided in either the outpatient department of a hospital or in a physician directed clinic;
    • The physician is on the premises available to perform medical duties at all times the facility is open and each patient is under the care of a hospital or clinic physician;
    • The facility has available for immediate use all the necessary cardio-pulmonary emergency diagnostic and therapeutic life saving equipment accepted by the medical community as medically necessary, e.g., oxygen, cardiopulmonary resuscitation equipment, or defibrillator;
    • The program is conducted in an area set aside for the exclusive use of the program while it is in session;
    • The program is staffed by personnel necessary to conduct the program safely and effectively, who are trained in both basic and advanced life support techniques and in exercise therapy for coronary disease.  Services of non-physician personnel must be furnished under the direct supervision of a physician.  Direct supervision means that a physician must be in the exercise program area.  It does not mean the physician must physically be present in the exercise room itself but must be immediately available and accessible for an emergency at all times;
    • The non physician personnel are employees of the physician, hospital, or clinic conducting the program and their services are incident to a physician's professional services.
 
Psychotherapy/Psychological Testing is not covered as a routine part of the evaluation or treatment of a candidate for a Cardiac Rehabilitation Program.  These services may be covered if the patient has a diagnosed mental, psychoneurotic, or personality disorder and/or exhibits symptoms of a severity that warrant evaluation and/or therapy.
 
Physical and Occupational Therapy services are not covered as a routine part of a Cardiac Rehabilitation Program. These services may be covered if the patient has a non-cardiac condition for which physical and/or occupational therapy are considered medically necessary.
 
Patient Education is not covered as a separately identifiable service when rendered as part of a Cardiac Rehabilitation Program.
 
Room and Board furnished to patients or family members by some free-standing facilities is not covered.
 
Cardiac Rehabilitation Programs meet primary coverage criteria for effectiveness and are eligible for coverage for patients who:
    • Have a clear clinical need for this type of program and are referred by their physician for participation in the program; and
    • Have one of the following in the 12 months prior to the initiation of the Cardiac Rehab program:
      • Stable angina pectoris;
      • History of acute myocardial infarction;
      • Coronary artery bypass, PTCA, or other types of percutaneous therapeutic coronary artery intervention, such as atherectomy,  stent placement, etc.;
      • Heart transplant or heart/lung transplant;
      • Repair or replacement of heart valve;
      • Class III or IV CHF;
      • Sustained ventricular tachycardia or fibrillation; or
      • Survivor following cardiac arrest.
 
Cardiac Rehabilitation programs meet primary coverage criteria for effectiveness and are eligible for coverage when rendered at a frequency of three sessions per week up to a duration of twelve weeks (36 sessions).
 
Other uses of cardiac rehabilitation is not covered based on benefit certificate primary coverage criteria that there be scientific evidence of effectiveness.
 
For contracts without primary coverage criteria, other uses of cardiac rehabilitation is considered investigational.  Investigational services are an exclusion in the member certificate of coverage.

Rationale:
This policy was was based on a clinical practice guideline issued by the U.S. Department of Health and Human Services (HHS) in 1995, which recommended cardiac rehabilitation services for patients with coronary heart disease (CHD) and with heart failure, including those awaiting or following cardiac transplantation.
 
2011 Update
A literature search through June 2011 did not identify any literature that would prompt a change in the coverage statement.
 
A 2010 Cochrane review by Davies and colleagues focused on exercise-based rehabilitation for adults with systolic heart failure (Davies, 2010). The authors searched for RCTs of exercise-based rehabilitation (alone or as part of comprehensive cardiac rehabilitation programs) in which patients were followed for at least 6 months. A total of 19 trials with 3,647 heart failure patients were identified; one large trial, HF-ACTION, contributed 2,331 (60%) patients. 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’ follow-up, did not find a statistically significant difference in mortality between groups (RR: 1.02, 95% CI: 0.70 to 1.51, p=0.90). Similarly, there was not a significant difference between groups in all-cause mortality in a pooled analysis of the 4 studies reporting more than 12 months’ follow-up (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 include patients with compensated heart failure.
 
Also in 2010, the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation published a position paper on cardiac rehabilitation. 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 20-30 minutes (preferably 45-60 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. The coverage statement has not been changed.
 
2012 Update
A search of the MEDLINE database was conducted through September 2012.  There was no new information identified that would prompt a change in the coverage statement.
 
2013 Update
A search of the MEDLINE database through 2013 did not reveal any new literature that would prompt a change in the coverage statement.
 
In 2012, the American College of Physicians, American College of Cardiology Foundation, American Heart Association/American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association and Society of Thoracic Surgeons published a joint guideline on management of stable ischemic heart disease (Qaseem, 2012). 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 at-risk patients at first diagnosis of stable ischemic heart disease. The current coverage statement is consistent with this guideline for physician directed out-patient cardiac rehabilitation.
 
2014 Update
A literature search conducted through June 2014 did not reveal any new information that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
A concern raised by the negative findings in the RAMIT trial is the majority of the RCTs evaluating cardiac rehabilitation was conducted in an earlier era of heart disease management, and may not be relevant to current care. Although no new RCT evidence was identified, several newer nonrandomized studies have been published since the RAMIT trial that corroborate prior RCT evidence about the benefit of cardiac rehabilitation after myocardial infarction. Two examples of such studies are provided here.
 
In 2013, Pack et al assessed the association between cardiac rehabilitation attendance and outcomes among 846 patients in a single Minnesota county who underwent coronary artery bypass grafting (CABG) from 1996 to 2007 (Pack, 2013). After propensity score adjustment, attending cardiac rehabilitation was associated with a reduced risk of 10-year mortality (hazard ratio 0.54, 95% CI 0.01 to 0.74, P<0.001).
 
In a longitudinal observational study, Coll-Fernandez et al compared mortality and subsequent ischemic event rates after acute MI between patients who underwent cardiac rehabilitation (n=521) and those who did not (n=522).  In multivariate analysis, patients who underwent cardiac rehabilitation had lower mortality than those who did not (adjusted hazard ratio 0.08, 95% CI 0.01 to 0.63, P=0.016).
 
Although these nonrandomized studies published since the RAMIT trial are limited by the potential for residual confounding by unobserved variables even after propensity-score adjustment or multivariable adjustment, they provide some additional evidence supporting the use of cardiac rehabilitation in the current era of cardiac care.
 
Ongoing Clinical Trials
A search of the online database ClinicalTrials.gov on 5/15/14 using the term “cardiac rehabilitation” as the intervention identified the following randomized studies that are currently enrolling patients:
 
Enhancing Standard Cardiac Rehabilitation With Stress Management Training in Patients With Heart Disease (ENHANCE) (NCT00981253) – This is a randomized, open-label trial designed to evaluate whether cardiac rehabilitation incorporating exercise and stress management is more effective than standard cardiac rehabilitation at improving cardiac biomarkers among patients with a diagnosis of coronary heart disease who are eligible for cardiac rehabilitation. Enrollment is planned for 150 subjects; the planned study completion date is May 2014.
 
Multi-Disciplinary Rehabilitation Program in Recently Hospitalized Patients With Preserved Ejection Fraction Heart Failure (NCT01914315) – This is a randomized, single-blinded (outcomes assessor-blinded) study to evaluate whether comprehensive cardiac rehabilitation is superior to standard care for patients with heart failure with preserved systolic function who are discharged after an acute heart failure event. Enrollment is planned for 1100 subjects; the planned study completion date is January 2016.
 
OPTImal CArdiac REhabilitation (OPTICARE) Following Acute Coronary Syndromes: A Randomized, Controlled Trial to Investigate the Benefits of an Expanded Educational and Behavioural Intervention Program (NCT01395095) – This is a randomized, open-label trial designed to compare two extended cardiac rehabilitation programs to a standard cardiac rehabilitation program among patients with acute coronary syndrome treated with primary or elective percutaneous coronary intervention or coronary surgery. Enrollment is planned for 1200 subjects; the planned study completion date is March 2016.
 
Effects of Homebased Training With Telemonitoring Guidance in Low to Moderate Risk Patients Entering Cardiac Rehabilitation (NCT01732419) – This is a randomized, open label trial to compare home-based cardiac rehabilitation to center-based cardiac rehabilitation among patients with acute coronary syndrome or a cardiac revascularization procedure. Enrollment is planned for 90 subjects; the planned study completion date is October 2014.
 
Efficacy of Physical Exercise in Cardiac Rehabilitation (NCT01617850) – This is a randomized, single-blinded trial to compare an “optimized” (higher-intensity” exercise program to a conventional program for improvement in exercise-related parameters among patients with angina pectoris, acute myocardial infarction, and chronic heart failure. Enrollment is planned for 70 subjects; the study completion date was listed as December 13. No results have been published.
 
Cardiopulmonary Rehabilitation for Adolescents and Adults With Congenital Heart Disease (NCT01822769) – This is a randomized, single-blinded trial to compare a formal 12-week outpatient cardiac rehabilitation program to standard care for adults and children with congenital heart disease and impaired aerobic capacity. Enrollment is planned for 60 subjects; the planned study completion date is December 2014.
 
Practice Guidelines and Position Statements
2013, the American College of Cardiology Foundation and the American Heart Association published updated guidelines on the management of heart failure (Yancy, 2013). These guidelines include the following Class IIA recommendation related to cardiac rehabilitation (Level of Evidence: B): Cardiac rehabilitation can be useful in clinically stable patients with HF to improve functional capacity, exercise duration, HRQOL [health-related quality of life], and mortality.
 
 
2015 Update
A literature search conducted through October 2015 did not reveal any new information that would prompt a change in the coverage statement.
 
2018 Update
A literature search conducted through April 2018 did not reveal any new information that would prompt a change in the coverage statement.
 
 
2019 Update
Annual policy review completed with a literature search using the MEDLINE database through April 2019. No new literature was identified that would prompt a change in the coverage statement.    
 
2020 Update
A literature search was conducted through April 2020.  There was no new information identified that would prompt a change in the coverage statement.  
 
2021 Update
Annual policy review completed with a literature search using the MEDLINE database through April 2021. No new literature was identified that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
Opotowsky et al compared cardiac rehabilitation to the standard of care in 28 subjects (mean age: 41.1 years) with moderate to severe congenital heart disease (Opotowsky, 2018). Cardiac rehabilitation was associated with a significant increase in peak oxygen consumption with no associated adverse events. There was also a nonsignificant improvement in peak work rate with cardiac rehabilitation as compared to standard of care (p=0.16) and a significant improvement in self-assessment of overall health (p<0.04). However, the study was limited by its small sample size and short-term follow-up.
 
Snoek et al evaluated 6 months of home-based mobile guided cardiac rehabilitation versus standard of care in 179 elderly subjects (mean age: 72 years) with a recent diagnosis of cardiovascular disease (Snoek, 2020). The primary outcome measure was peak oxygen uptake after 6 months. Results revealed that changes in peak oxygen uptake were greater in the cardiac rehabilitation group as compared to the control at both 6 and 12 months. The overall incidence of adverse events was low and did not differ between groups. A limitation of the study was that the authors used home-based mobile guided cardiac rehabilitation as an alternative to exercise-based cardiac rehabilitation and not for comprehensive cardiac rehabilitation, because the authors did not include all core components of cardiac rehabilitation in their intervention.
 
Zeng et al reported outcomes of a Medicare-sponsored demonstration of 2 intensive lifestyle modification programs in patients with symptomatic coronary heart disease: the Cardiac Wellness Program of the Benson-Henry Mind Body Institute and the Dr. Dean Ornish Program for Reversing Heart Disease (Zeng, 2013). This analysis included 461 participants and 1,795 matched controls using Medicare claims data from 1998 to 2008. Four matched controls were sought for each participant from Medicare claims data, 2 of whom had received traditional cardiac rehabilitation within 12 months following their cardiac events (cardiac rehabilitation controls) and 2 of whom had not (non-cardiac rehabilitation controls). Outcomes included mortality rates during the 3 post-enrollment years, total hospitalizations, hospitalizations with a cardiac-related principal discharge diagnosis, and Medicare-paid costs of care. Of the 324 participants in the Benson-Henry Mind Body Medical Institute program analysis, the authors concluded that during the active intervention and follow-up years, total, cardiac, and non-cardiac hospitalizations were lower in the Benson-Henry program participants than their controls for each comparison (p<0.001). The investigators further reported that after year 1, the mortality rate was 1.5% in the Benson-Henry program participants compared with 2.5% and 4.2%, respectively, in cardiac rehabilitation and non-cardiac rehabilitation controls. After year 3, comparable figures were 6.2% in Benson-Henry program participants, 10.5% in cardiac rehabilitation controls, and 11.0% in non-cardiac rehabilitation controls. These mortality differences for the Benson-Henry program participants reached borderline significance (p=0.08).
 
Casey et al reported the results of a case series that evaluated the effects of an intensive cardiac rehabilitation program, incorporating components of the Benson-Henry Institute Cardiac Wellness Program at a single center (Casey, 2009). From 1997 to 2005, 637 patients with coronary artery disease were enrolled and completed the program, which consisted of 13 weekly 3 hour sessions with supervised exercise, relaxation techniques, stress management, and behavioral interventions. The mean age of participants was 63 years (range 27 to 92 years); men comprised 72% of the study population. Results revealed significant improvements in clinical (blood pressure, lipids, weight, exercise conditioning, frequency of symptoms of chest pain, and shortness of breath) and psychological outcomes (general severity index, depression, anxiety, and hostility) (p<0.0001) with the program.
 
2022 Update
Annual policy review completed with a literature search using the MEDLINE database through April 2022. No new literature was identified that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
Jafri et al conducted a retrospective cohort study to evaluate home-based cardiac rehabilitation (HBCR) in patients with established cardiovascular disease (Jafri, 2021). A total of 269 patients at a Veterans Affairs Medical Center were eligible for inclusion (HBCR group, n=157; non-HBCR control group, n=100); 12 patients were excluded due to having outcomes less than 90 days after enrollment (study follow-up period was between 3 to 12 months). A majority of patients (98%) were male, and the mean age was 72 years. The primary outcome was composite all-cause mortality and hospitalizations and secondary outcomes were all-cause hospitalization, all-cause mortality, and cardiovascular hospitalizations. The primary composite outcome occurred in both the HBCR (n=30) and control (n=30) (adjusted HR 0.56; 95% CI 0.33 to 0.95; p=.03). All-cause mortality occurred in 6.4% of HBCR patients versus 13% of the control group (adjusted HR 0.43; 95% CI 0.18 to 1.0; p=.05). There was no difference in cardiovascular or all-cause hospitalizations between groups.
 
2023 Update
Annual policy review completed with a literature search using the MEDLINE database through April 2023. No new literature was identified that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
No RCTs evaluating the Pritikin Program were identified. Lakhani et al conducted a prospective, nonrandomized study that compared intensive cardiac rehabilitation with the Pritikin Program and traditional outpatient cardiac rehabilitation (Lakhani, 2023). The primary outcomes of interest were change in diet quality and quality of life from baseline to visit 24. There was a significant improvement in diet quality but not in quality of life between the Pritikin Program and traditional cardiac rehabilitation groups. Body mass index was also improved in patients who received intensive rehabilitation. Limitations of the study include a short follow-up and lack of data for cardiovascular outcomes.
 
Racette et al published 7-year outcomes from the first institution to implement the Pritiken Program (Racette, 2022). Retrospective data for 1,507 patients who received the intensive cardiac rehabilitation program and 456 patients who received traditional cardiac rehabilitation were compared. Outcomes of interest (e.g., anthropometric measures, dietary patterns, 6-minute walk distance [6MWD], grip strength, and HRQoL) all improved with the Pritiken Program. Significant benefit of the Pritiken Program compared to traditional cardiac rehabilitation were noted for change in body weight (p<.0001), body mass index (p<.0001), waist circumference (p<.0001), and diet quality as measured by the Rate Your Plate score (p<.0001). There was no difference in 6MWD or grip strength between groups. Cardiovascular outcomes, including rehospitalization or mortality, were not assessed.
 
Several meta-analyses/systematic reviews are available for virtual cardiac rehabilitation (Jin Choo, 2022; Nacarato, 2022; Cavalheiro, 2021; Cruz-Cobo, 2022; Maulana, 2022; Ramachandran, 2022). In general, these reviews have found significant effects on physical activity, cardiovascular risk factors, and quality of life, but evidence for cardiovascular outcomes is limited.
 
The analysis by Cruz-Cobo et al included 20 randomized studies (N=4,535) of mobile health interventions in patients who had experienced a coronary event (Cruz-Cobo, 2022). Beneficial effects of mobile health interventions were found for exercise capacity, physical activity, adherence to treatment, and quality of life. All-cause hospital readmission (p=.04) and hospital readmission for cardiovascular causes (p=.05) were statistically lower in the mobile health intervention group compared to the control group, but these may not be clinically relevant differences (point estimates for actual risk differences were -0.03 and -0.04, respectively). There was no difference between groups in mortality. A major limitation of this study is lack of clarity of how many individuals received mobile health interventions for the purpose of cardiac rehabilitation.
 
Numerous RCTs with virtual cardiac rehabilitation have been published (Nagatomi, 2022; Brouwers, 2022; Brouwers, 2021; Indraratna, 2022; Snoek, 2020; Piotrowicz, 2020; Yudi, 2021; Hakala, 2021; Dalli, 2022; Maddison, 2019; Nkonde, 2022). Of these, only 2 have reported results for cardiovascular outcomes of interest. Indraratna et al found that unplanned hospital readmissions and cardiac readmissions were significantly lower with a smartphone-based intervention to facilitate the transition to outpatient cardiac care (including rehabilitation) compared to usual care among 164 patients being discharged after hospitalization for acute coronary syndrome or heart failure (Indraratna, 2022). However, only 100 patients in the study received cardiac rehabilitation after discharge and rehospitalization rates were not provided for this cohort alone. Other limitations of this study include short duration of follow-up (6 months) and that enrollment was terminated in March 2020 so the study may not reflect how usual care is delivered in the post-COVID-19 pandemic era. Piotrowicz et al conducted a 9-week RCT of telerehabilitation compared to usual care in 850 patients with heart failure (Piotrowicz, 2020). Both groups had a median follow-up of 793 days. The primary outcome (days alive and out of the hospital through end of follow-up) was similar between groups (median, 775 days [telerehabilitation] vs. 776 days [usual care]). There was also no difference between telerehabilitation and usual care in all-cause hospitalization (HR, 0.913; 95% CI, 0.762 to 1.093), cardiovascular hospitalization (HR, 0.837; 95% CI, 0.667 to 1.050), all-cause mortality (HR, 1.035; 95% CI, 0.706 to 1.517), or cardiovascular mortality (HR, 0.985; 95% CI, 0.619 to 1.569). Since the study only included patients with heart failure, the results may not be applicable to patients with other forms of heart disease. Other limitations include a lack of power for hospitalization and mortality outcomes, and that the cardiac monitoring device used in the study may not reflect the effect of video- or smartphone-based virtual rehabilitation methods used in current practice.
 
Nkonde-Price et al conducted a retrospective study of virtual cardiac rehabilitation compared to traditional cardiac rehabilitation in a cohort of 2,556 patients with cardiovascular disease (Nkonde-Price, 2022). Virtual cardiac rehabilitation consisted of home-based cardiac rehabilitation using a mobile phone application linked to a wearable smartwatch, self-directed exercise sessions, weekly nurse phone calls, and health education for 8 weeks. The primary outcome, all-cause hospitalization during 12 months of follow-up, was lower in patients who experienced the virtual cardiac rehabilitation program compared to traditional outpatient cardiac rehabilitation (14.8% vs. 18.1%; OR, 0.79; 95% CI, 0.64 to 0.97; p=.03). There was no difference between groups in 30-day or 90-day all-cause or cardiovascular hospitalization. Mortality was not addressed.
 
In 2013, the American College of Cardiology Foundation and the American Heart Association updated their joint guidelines on the management of heart failure (Yancy, 2013). These guidelines included the following class IIA recommendation on cardiac rehabilitation (level of evidence: B): “Cardiac rehabilitation can be useful in clinically stable patients with heart failure to improve functional capacity, exercise duration, health-related quality of life, and mortality.” The 2022 guideline from the same organizations did not include additional information on cardiac rehabilitation (Heidenreich, 2022).

CPT/HCPCS:
93797Physician or other qualified health care professional services for outpatient cardiac rehabilitation; without continuous ECG monitoring (per session)
93798Physician or other qualified health care professional services for outpatient cardiac rehabilitation; with continuous ECG monitoring (per session)
G0422Intensive cardiac rehabilitation; with or without continuous ecg monitoring with exercise, per session
G0423Intensive cardiac rehabilitation; with or without continuous ecg monitoring; without exercise, per session

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