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National Coverage Determination (NCD)

Cardiac Rehabilitation Programs for Chronic Heart Failure

20.10.1

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Tracking Information

Publication Number
100-3
Manual Section Number
20.10.1
Manual Section Title
Cardiac Rehabilitation Programs for Chronic Heart Failure
Version Number
1
Effective Date of this Version
02/18/2014
Ending Effective Date of this Version
Implementation Date
08/18/2014
Implementation QR Modifier Date

Description Information

Benefit Category
Cardiac Rehabilitation Programs


Please Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

Item/Service Description

A.      General

As per sections 1861(s)(2)(CC) and 1861(eee)(1) of the Social Security Act, items and services furnished under a Cardiac Rehabilitation (CR) program may be covered under Medicare Part B. Among other things, Medicare regulations at 42CFR410.49 define key terms, address the components of a CR program, establish the standards for physician supervision, and limit the maximum number of program sessions that may be furnished. The regulations also describe the cardiac conditions that would enable a beneficiary to obtain CR services.

Effective for dates of service on and after January 1, 2010, coverage is permitted for beneficiaries who have experienced one or more of the following:

  • Acute myocardial infarction within the preceding 12 months
  • Coronary artery bypasses surgery
  • Current stable angina pectoris
  • Heart valve repair or replacement
  • Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting
  • A heart or heart-lung transplant

The Centers for Medicare & Medicaid Services (CMS) may add “other cardiac conditions as specified through a national coverage determination” (See 42 CFR §410.49(b)(1)(vii)).
Indications and Limitations of Coverage

B.      Nationally Covered Indications

Effective for dates of service on and after February 18, 2014, CMS has determined that the evidence is sufficient to expand coverage for cardiac rehabilitation services under 42 CFR §410.49(b)(1)(vii) to beneficiaries with stable, chronic heart failure, defined as patients with left ventricular ejection fraction of 35% or less and New York Heart Association (NYHA) class II to IV symptoms despite being on optimal heart failure therapy for at least six weeks. Stable patients are defined as patients who have not had recent (≤ 6 weeks) or planned (≤ 6 months) major cardiovascular hospitalizations or procedures. (See section A above for other indications covered under 42 CFR §410.49(b)(1)(vii)).

C.      Nationally Non-Covered Indications

Any cardiac indication not specifically identified in 42 CFR §410.49(b)(1)(vii) or identified as covered in this NCD or any other NCD in relation to cardiac rehabilitation services is considered non-covered.

D.      Other

NA

(This NCD last reviewed February 2014.)
Cross Reference
Claims Processing Instructions

Transmittal Information

Transmittal Number
171
Coverage Transmittal Link
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R171NCD.pdf
Revision History

07/2014 - The purpose of this Change Request (CR) is effective for dates of service on and after February 18, 2014, Medicare covers cardiac rehabilitation services to beneficiaries with stable, chronic heart failure defined as patients with left ventricular ejection fraction of 35% or less and New York Heart Association (NYHA) class II to IV symptoms despite being on optimal heart failure therapy for at least 6 weeks. Effect date: 02/18/2014. Implementation date: 08/18/2014. (TN 171) (CR8758)
Other

National Coverage Analyses (NCAs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with NCAs, from the National Coverage Analyses database.

Coding Analyses for Labs (CALs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with CALs, from the Coding Analyses for Labs database.

Additional Information

Other Versions
Title Version Effective Between
Cardiac Rehabilitation Programs for Chronic Heart Failure 1 02/18/2014 - N/A You are here
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Reasons for Denial
Note: This section has not been negotiated by the Negotiated RuleMaking Committee. It includes CMS’s interpretation of it’s longstanding policies and is included for informational purposes. Tests for screening purposes that are performed in the absense of signs, symptoms, complaints, or personal history of disease or injury are not covered except as explicity authorized by statue. These include exams required by insurance companies, business establishments, government agencies, or other third parties. Tests that are not reasonable and necessary for the diagnosis or treatment of an illness or injury are not covered according to the statue. Failure to provide documentation of the medical necessity of tests may result in denial of claims. The documentation may include notes documenting relevant signs, symptoms, or abnormal findings that substantiate the medical necessity for ordering the tests. In addition, failure to provide independent verification that the test was ordered by the treating physician (or qualified nonphysician practitioner) through documentation in the physician’s office may result in denial. A claim for a test for which there is a national coverage or local medical review policy will be denied as not reasonable and necessary if it is submitted without an ICD-9-CM code or narrative diagnosis listed as covered in the policy unless other medical documentation justifying the necessity is submitted with the claim. If a national or local policy identifies a frequency expectation, a claim for a test that exceeds that expectation may be denied as not reasonable and necessary, unless it is submitted with documentation justifying increased frequency. Tests that are not ordered by a treating physician or other qualified treating nonphysician practitioner acting within the scope of their license and in compliance with Medicare requirements will be denied as not reasonable and necessary. Failure of the laboratory performing the test to have the appropriate Clinical Laboratory Improvement Act of 1988 (CLIA) certificate for the testing performed will result in denial of claims.
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