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National Coverage Analysis (NCA) Tracking Sheet

Cardiac Rehabilitation

CAG-00089N

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Issue

Cardiac rehabilitation is described by the U.S. Public Health Service as consisting of "comprehensive, long-term programs involving medical evaluation, prescribed exercise, cardiac risk factor modification, education, and counseling". It further states that 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".

Medicare covers supervised cardiac rehabilitation as a physician service. The current Medicare policy covers physician supervised cardiac rehabilitation for patients who (1) have a documented diagnosis of acute myocardial infarction within the preceding 12 months; or (2) have had coronary bypass surgery; and/or (3) have stable angina pectoris. CMS (formerly HCFA) will evaluate whether or not current literature supports the use of supervised cardiac rehabilitation for the following additional indications: (1) heart valve replacement; (2) angioplasty; (3) heart or heart lung transplant; and (4) congestive heart failure. The review is limited to phase II rehabilitation programs. CMS will not consider acute inpatient programs or outpatient maintenance programs.

We will be particularly interested in evidence bearing on the need for physician supervision in cardiac rehabilitation. If the evidence suggests that cardiac rehabilitation provides a benefit but that physician supervision is not required, it cannot be covered under the current statute. (A legislative change may be required to provide Medicare coverage in such instances, e.g., as a non-physician benefit.)

National Coverage Determinations

Benefit Category

Incident to a physician's professional Service

Requestor Information

Requestor Name Requestor Letter
CMS internally generated request N/A
N/A

Important Dates

Formal Request Accepted and Review Initiated
02/20/2001
Expected NCA Completion Date
06/29/2005
Public Comment Period
02/20/2001 - 03/20/2001
Proposed Decision Memo Due Date
Proposed Decision Memo Released
Proposed Decision Memo Public Comment Period
Decision Memo Released

Contacts

Lead Analysts
JoAnna Baldwin
Lead Medical Officers
Lawrence Schott, M.D., M.S.

Medicare Benefit Category Determination Date

Actions Taken

February 20, 2001

HCFA internally generated a national coverage review for supervised cardiac rehabilitation.

April 2, 2001

Our preliminary review of the literature has provided us with inadequate evidence addressing the role of the physician in cardiac rehabilitation programs. Organizations, physicians, or patients having evidence, especially peer-reviewed literature discussing clinical trials, that speaks to the need for physician supervision in cardiac rehabilitation programs, should promptly submit it to HCFA at 7500 Security Blvd., S3-02-01, Baltimore, MD 21210.

May 4, 2001

HCFA met with representatives from the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR), the American Hospital Association (AHA), and the American College of Cardiology (ACC).

May 11, 2001

HCFA received 80 articles on cardiac rehabilitation from AACVPR. Due to the large volume of articles contained in this submission as well as a pending benefit category determination, HCFA will restart its 90-day clock for the national coverage process in order to provide ample time for complete and accurate review. The new due date for the decision is August 11, 2001.

July 12, 2001

CMS (formerly HCFA) met with representatives from the American College of Cardiology (ACC), the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR), and several medical experts in the field of cardiac rehabilitation. Medical aspects of the indications under review, as well as physician supervision, were discussed.

August 8, 2001

CMS has identified additional relevant clinical literature. In order to allow for a full evaluation of this literature, the due date will be extended to September 28, 2001.

September 26, 2001

Additional time is needed to complete CMS internal review of the issue. We are specifically focusing on what level of physician supervision would allow cardiac rehabilitation to be a covered benefit under the Medicare program. The new due date is October 15, 2001.

November 5, 2001

CMS has requested that the Office of the Inspector General assist CMS in determining whether outpatient cardiac rehabilitation programs meet the current physician supervision requirements as outlined in the existing coverage policy. A new due date will be announced after CMS has received the OIG's report.

December 10, 2001

In order to address concerns that have been raised since our last tracking sheet update on November 5, 2001, we are offering the following information:

A large number of internal and external questions were raised concerning our potential clarification of the physician supervision required of cardiac rehabilitation programs. As a result, the OIG was asked to determine the current status of physician supervision in present programs (OIG Memorandum, qq1.jpg, page 2).

No additional information regarding this work is available until a final report is issued by the OIG. At that time, it will be posted to the OIG website for public access.

June 29, 2005

Due to the length of time this reconsideration was pending, CMS is closing this analysis without changing coverage for cardiac rehabilitation programs and opening a new reconsideration to research and evaluate cardiac rehabilitation using current evidence. The new reconsideration will be listed under a separate tracking sheet (00098R) and will follow the MMA established timelines.
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