Cardiac Rehabilitation

Cardiac rehabilitation is defined as the use of various modalities of treatment to improve cardiac or pulmonary function, as well as tissue perfusion and oxygenation through which selected patients are restored to, and maintained at, either a pre-illness level of activity or a new and appropriate level of adjustment.  

Cardiac rehabilitation does not require preauthorization.  

Professional

Cardiac rehabilitation is scientifically validated if started within four months of:  

• An acute myocardial infarction; 
• Coronary artery angioplasty, with or without stent placement, or other scientifically validated procedure to clear blocked coronary vessels; 
• Heart or coronary artery surgery;  
• Heart transplant; or  
• Heart-lung transplant.  

Cardiac rehabilitation is scientifically validated for treatment of congestive heart failure and stable angina initially and after significant changes in clinical status. All other uses of cardiac rehabilitation are investigative.  

Note: The diagnosis and time frame may vary based on the member’s contract. If the member has benefits for cardiac rehabilitation but does not meet the contract criteria, then it is denied as a contract exclusion, not investigative.  

Institutional

Benefit Provisions
Benefits are provided for medically necessary outpatient facility rehabilitation programs, according to the terms of the subscriber’s contract. In addition, the following services are covered when provided as part of the approved rehabilitation program:  

• Initial rehabilitation evaluation  
• Exercise sessions  
• Concurrent monitoring during the exercise session for high-risk patients  

The patient’s condition must be such that rehabilitation can only be carried out safely under the direct, continuing supervision of a physician and in a controlled hospital environment.  

Services are provided at any therapeutic level, limited to the number of sessions listed in the subscriber’s contract, for the following diagnoses occurring during the four months prior to the start date of a cardiac program:  

• An acute myocardial infarction
• Coronary bypass surgery  
• Coronary artery angioplasty or other procedure to clear blocked vessels  
• Heart transplant  
• Heart-lung transplant  
• Heart valve surgery  

All other uses of cardiac rehabilitation are investigative.