Highmark Commercial Medical Policy - Pennsylvania
Medical Policy: V-1-018
Topic: Cardiac Rehabilitation Programs, Phase II Outpatient
Section: Visits
Effective Date: July 31, 2017
Issue Date: July 31, 2017
Last Reviewed: June 2017

Cardiac rehabilitation program, phase II refers to comprehensive medically supervised programs in the outpatient setting that aim to improve the function of patients with heart disease and prevent future cardiac events.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Position Coverage is subject to the specific terms of the member’s benefit plan.

Cardiac rehabilitation programs, Phase II Outpatient may be considered medically necessary when the following criteria are met:

The following are considered not medically necessary:

Following the initial evaluation, services provided in conjunction with a phase II outpatient cardiac rehab program may be considered medically necessary for up to 36 sessions, 3 sessions per week, for a 12-week period. The need for supervised exercise sessions can be determined by the patient’s risk stratification as follows:

A routine cardiac rehabilitation session usually consists of an exercise training session lasting 20-60 minutes and at least one of the following services:

Cardiac rehabilitation exercise programs beyond the initial 12-week/36 session will require individual medical review. If documentation substantiates that additional sessions are medically necessary to reach a realistic and achievable increase in work capacity, the number of services may be extended, but not exceed a maximum of 24 weeks or 72 sessions.

Maintenance exercise programs undertaken by the patient after formal freestanding clinic or facility based programs are completed, are not covered.

Generally, psychotherapy and psychological testing are not considered medically necessary for all cardiac rehabilitation patients. However, if a patient has been diagnosed with a mental, psychoneurotic or personality disorder, psychotherapy performed by a psychiatrist or a psychologist may be considered medically necessary.  In addition, psychological diagnostic testing of a cardiac rehabilitation patient who exhibits symptoms of mental illness or mental problems (e.g., anxiety disorder associated with the cardiac disease) may be considered medically necessary.

Physical and/or occupational therapies are considered not medically necessary in conjunction with cardiac rehabilitation services unless performed for an unrelated diagnosis (e.g., a patient who is recuperating from an acute phase of heart disease may have also had a stroke which could require physical and/or occupational therapies).

Repeat participation in an outpatient cardiac rehabilitation program in the absence of another qualifying cardiac event is considered experimental/investigational. Scientific evidence does not support the need for repeat cardiac rehabilitation in the absence of cardiac events.

Educational services (e.g., lectures, counseling) that may be provided as part of a cardiac rehabilitation exercise program are not eligible for separate reimbursement.

Phase II cardiac rehabilitation services that do not meet the medical necessity criteria and frequency guidelines outlined on this policy will be denied as not medically necessary.

Procedure Codes
93015, 93016, 93017, 93018, 93797, 93798, 99205, 99215, G0422, G0423


FEP Guidelines


Refer to the documentation attachment for additional information.


Professional Statements and Societal Positions

In 2013, the American College of Cardiology Foundation and the American Heart Association published updated guidelines on the management of heart failure.  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 heart failure to improve functional capacity, exercise duration, HRQOL (health-related quality of life), and mortality.

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.  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.


Place of Service: Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

Phase II cardiac rehabilitation is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances including, but not limited to the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.


The policy position applies to all commercial lines of business


Denial Statements

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

A network provider cannot bill the member for the non-covered service.

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Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

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The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer: If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

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U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

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