Clinical UM Guideline

 

Subject: Pulmonary Rehabilitation
Guideline #:  CG-REHAB-03 Publish Date:    08/29/2018
Status: Reviewed Last Review Date:    07/26/2018

Description

This document addresses the use of pulmonary rehabilitation for the treatment of various lung conditions. Pulmonary rehabilitation (PR) is an individually tailored multidisciplinary program of care for people with chronic respiratory impairment.

Clinical Indications

Medically Necessary:

  1. Pulmonary rehabilitation (PR) is considered medically necessary in individuals who meet the following criteria:
    1. Individual is free from the following comorbidities:
      1. Conditions that may interfere with the individual undergoing the rehabilitative process, including but not limited to:
        1. Advanced arthritis; or
        2. Disruptive behavior; or
        3. Inability to learn; and
      2. Conditions that may place the individual at undue risk during exercise training, including but not limited to:
        1. Recent myocardial infarction; or
        2. Severe pulmonary hypertension; or
        3. Unstable angina.

AND meet the following criteria from B OR C:

  1. Individual with chronic respiratory impairment that, despite optimal medical management, results in disabling dyspnea associated with a restriction in ordinary activities and significant impairment in quality of life. Candidates must also be motivated to participate in a PR program. Individuals meeting these criteria may include:
    1. Those suffering with any of the following:
      1. Chronic obstructive pulmonary disease such as:
        1. Asthma; or
        2. Bronchiectasis; or
        3. Chronic bronchitis; or
        4. Cystic fibrosis; or
        5. Emphysema; or
      2. Restrictive diseases such as:
        1. Chest wall disease; or
        2. Interstitial disease; or
        3. Post-polio syndrome; or
        4. Selected neuromuscular disorders; or
        5. Thoracic cage abnormalities; or
      3. Stable lung cancer;

OR

  1. Individual is preparing for OR recovering from surgical interventions such as:
    1. Lung transplantation; or
    2. Lung volume reduction surgery; or
    3. Post-operative states (for example, thoracic or abdominal surgery).
  1. Repeat PR programs may be considered medically necessary for individuals undergoing a second PR program in connection with lung transplantation or lung volume reduction surgery when medical necessity criteria for PR are met.

Not Medically Necessary:

PR provided in the inpatient setting is considered not medically necessary when medical necessity criteria for PR are not met.

Place of Service/Duration

Place of Service: Ambulatory/Outpatient
Duration: Frequency and duration of the program may vary according to the individual’s needs. It is not uncommon for the individual to receive therapy 3 times per week for 4 to 6 weeks.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

HCPCS

 

G0237

Therapeutic procedures to increase strength or endurance of respiratory muscles, face to face, one on one, each 15 minutes (includes monitoring)

G0238

Therapeutic procedures to improve respiratory function, other than described by G0237, one on one, face to face, per 15 minutes (includes monitoring)

G0239

Therapeutic procedures to improve respiratory function or increase strength or endurance of respiratory muscles, two or more individuals (includes monitoring)

G0302-G0304

Pre-operative pulmonary surgery services for preparation for LVRS [includes codes G0302, G0303, G0304]

G0305

Post-discharge pulmonary surgery services after LVRS, minimum of 6 days of services

G0424

Pulmonary rehabilitation, including exercise (includes monitoring), one hour, per session, up to two sessions per day

S9473

Pulmonary rehabilitation program, non-physician provider, per diem

 

 

ICD-10 Diagnosis

 

 

All diagnoses

   
Discussion/General Information

According to the American Thoracic Society (ATS) pulmonary rehabilitation is defined as:

A comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies, which include, but are not limited to, exercise training, education, and behavior change, designed to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long-term adherence of health-enhancing behaviors.

The PR program combines an accurate diagnosis with therapy, emotional support, and education to stabilize or reverse both the physio- and psychopathology of pulmonary disease.

The goal of PR is to:

Several studies have demonstrated important benefits of PR including reducing dyspnea (shortness of breath) and improving exercise capacity, total energy expenditure, and quality of life (QOL) (Dodd, 2012; Dowman, 2017; Egan, 2012; Mandal, 2012; McFarland, 2012). A number of studies have demonstrated that PR has also been associated with decreases in hospitalization rates and the overall utilization of medical resources. A randomized trial conducted by Ries and colleagues (2005) demonstrated a non-significant trend for PR to increase 5-year survival. Mandal and colleagues (2012) conducted a pilot randomized controlled trial (RCT) with 30 subjects with non-cystic fibrosis bronchiectasis. The primary outcome measure was the incremental shuttle walking test (ISWT). Study authors reported no benefit for subjects in the control group, who received chest physiotherapy only, at the end of 8 weeks of therapy, or at 20 weeks post-therapy. Subjects in the experimental group, who received chest physiotherapy in conjunction with PR, demonstrated significant benefits (relative to baseline values) on ISWT (p=0.03), endurance walk test (EWT) (p=0.01), Leicester Cough Questionnaire (LCQ) (p<0.001), and St. George's Respiratory Questionnaire (SGRQ) (p<0.001). At 12 weeks following the last training session, the experimental group also showed continued and significant improvement (relative to baseline values) for ISWT (p=0.04) and EWT (p=0.003). LCQ and SGRQ also were significantly improved compared with baseline (p<0.001 for both measures).  Limitations of this study included the lack of statistical comparisons between treatment and control groups, small study population, lack of blinding, and lack of clinically relevant primary outcome measures. Additional well-designed RCTs are necessary to confirm these initial findings.

An RCT by Lai and colleagues (2017) compared a preoperative, high-intensity, 7-day pulmonary rehabilitation program to standard care for 101 subjects preparing for lung cancer lobectomy. The primary endpoint was postoperative complications within 30 days of surgery, including atelectasis, acute respiratory distress syndrome, respiratory failure, mechanical ventilation, deep vein thrombosis/pulmonary embolism, and empyema/pneumonia. The researchers found that postoperative complications were significantly lower in the pulmonary rehabilitation group compared to the standard care group (5/51, 9.8% versus 14/50, 28%; p=0.019). In addition, the pulmonary rehabilitation group was able to walk further in 6 minutes (22.9 ± 25.9 m versus 4.2 ± 9.2 m), had better peak expiratory flow (increase of 25.2 ± 24.6 l/min versus 4.2 ± 7.7 l/min), and had a shorter postoperative hospital stay (6.1 ± 3.0 versus 8.7 ± 4.6 days; p=0.001). A total of 6 subjects did not complete the 7-day pulmonary rehabilitation program due to needing surgery early (2 cases), lack of endurance (2 cases), and perceived lack of benefit (2 cases). Overall, the researchers concluded that individuals with lung cancer benefit from a high-intensity, systematic, preoperative pulmonary rehabilitation program and have fewer postoperative complications.

In a joint consensus statement by the American Thoracic Society and the European Respiratory Society (2015), the following statement was made:

PR has demonstrated effectiveness for several respiratory conditions other than COPD. Randomized controlled trials demonstrating its beneficial effects on exercise capacity, symptoms, and/or health-related quality of life are available in interstitial lung disease, bronchiectasis, asthma, cystic fibrosis, lung transplantation, lung cancer, and pulmonary hypertension.

In a joint guideline published by the American College of Chest Physicians and the Canadian Thoracic Society (2016), the following recommendations were made for individuals with severe, or very severe COPD:

In a joint guideline by the American Thoracic Society and the European Respiratory Society (Wedzicha, 2017), the following statement was made:

Pulmonary rehabilitation implemented within 3 weeks after discharge following a COPD exacerbation reduces hospital admissions and improves quality of life, while pulmonary rehabilitation implemented within 8 weeks after discharge increases exercise capacity.

Multiple systematic reviews have been published that support the efficacy of PR in managing COPD-related illnesses (Lee, 2016; Mantoani, 2016; Meshe, 2016; Paneroni, 2017) including a Cochrane Review which included 20 studies representing a total of 1477 individuals (Puhan, 2016).

Frequency and duration of the program may vary according to the individual’s needs. It is not uncommon for the person to receive therapy 3 times per week for 4 to 6 weeks.

The permanence of outcomes achieved by PR appears to be more related to the structure and duration of the supervised maintenance component of the program than the intensity of the program. The long-term outcome data are somewhat limited in this respect. To achieve sustained results, it is important that the person continues with the at-home regimen outlined in the PR program.

There is currently no evidence that repeat pulmonary rehabilitation programs result in additive long-term benefits in terms of dyspnea, exercise tolerance, or health-related quality of life (HR-QOL) measures.

References

Peer Reviewed Publications:

  1. Busby AK, Reese RL, Simon SR. Pulmonary rehabilitation maintenance interventions: a systematic review. Am J Health Behav. 2014; 38(3):321-330.
  2. Carr SJ, Hill K, Brooks D, Goldstein RS. Pulmonary rehabilitation after acute exacerbation of chronic obstructive pulmonary disease in patients who previously completed a pulmonary rehabilitation program. J Cardiopulm Rehabil Prev. 2009; 29(5):318-324.
  3. Cejudo P, López-Márquez I, López-Campos JL, et al. Exercise training in patients with chronic respiratory failure due to kyphoscoliosis: a randomized controlled trial. Respir Care. 2014; 59(3):375-382.
  4. Di Meo F, Pedone C, Lubich S, et al. Age does not hamper the response to pulmonary rehabilitation of COPD patients. Age Ageing. 2008; 37(5):530-535.
  5. Dodd JW, Marns PL, Clark AL, et al. The COPD Assessment Test (CAT): short- and medium-term response to pulmonary rehabilitation. COPD. 2012; 9(4):390-394.
  6. Dowman LM, McDonald CF, Hill CJ, et al. The evidence of benefits of exercise training in interstitial lung disease: a randomised controlled trial. Thorax. 2017; 72(7):610-619.
  7. Egan C, Deering BM, Blake C, et al. Short term and long term effects of pulmonary rehabilitation on physical activity in COPD. Respir Med. 2012; 106(12):1671-1679.
  8. Ferguson GT. Recommendations for the management of COPD. Chest. 2000; 117(2 Suppl):23S-28S.
  9. Foglio K, Bianchi L, Ambrosino N. Is it really useful to repeat outpatient pulmonary rehabilitation programs in patients with chronic airway obstruction? A 2-year controlled study. Chest. 2001; 119(6):1696-1704.
  10. Griffiths TL, Phillips CJ, Davies S, et al. Cost effectiveness of an outpatient multidisciplinary pulmonary rehabilitation programme. Thorax. 2001; 56(10):779-784.
  11. Hoffman M, Chaves G, Ribeiro-Samora GA, et al. Effects of pulmonary rehabilitation in lung transplant candidates: a systematic review. BMJ Open. 2017; 7(2):e013445.
  12. Kaplan RM, Ries AL, Reilly J, Mohsenifar Z. Measurement of health-related quality of life in the national emphysema treatment trial. Chest. 2004; 126(3):781-789.
  13. Ketelaars CA, Abu-Saad HH, Schlosser MA, et al. Long-term outcome of pulmonary rehabilitation in patients with COPD. Chest. 1997; 112(2):363-369.
  14. Lai Y, Su J, Qui P, et al. Systematic short-term pulmonary rehabilitation before lung cancer lobectomy: a randomized trial. Interact Cardiovasc Thorac Surg. 2017; 25(3):476-483.
  15. Lee AL, Hill CJ, McDonald CF, Holland AE. Pulmonary rehabilitation in individuals with non-cystic fibrosis bronchiectasis - a systematic review. Arch Phys Med Rehabil. 2017; 98(4):774-782.
  16. Mahler DA. Pulmonary rehabilitation. Chest. 1998; 113(4 Suppl):263S-268S.
  17. Maltais F, Bourbeau J, Shapiro S, et al. Effects of home-based pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: a randomized trial. Ann Intern Med. 2008; 149(12):869-878.
  18. Mandal P, Sidhu MK, Kope L, et al. A pilot study of pulmonary rehabilitation and chest physiotherapy versus chest physiotherapy alone in bronchiectasis. Respir Med. 2012; 106(12):1647-1654.
  19. Mantoani LC, Rubio N, McKinstry B, et al. Interventions to modify physical activity in patients with COPD: a systematic review. Eur Respir J. 2016; 48(1):69-81.
  20. McFarland C, Willson D, Sloan J, Coultas D. A randomized trial comparing 2 types of in-home rehabilitation for chronic obstructive pulmonary disease: a pilot study. J Geriatr Phys Ther. 2012; 35(3):132-139.
  21. Meshe OF, Claydon LS, Bungay H, Andrew S. The relationship between physical activity and health status in patients with chronic obstructive pulmonary disease following pulmonary rehabilitation. Disabil Rehabil. 2016; 39(8):746-756.
  22. Moore E, Newson R, Joshi M, et al. Effects of pulmonary rehabilitation on exacerbation number and severity in people with COPD: an historical cohort study using electronic health records. Chest. 2017; 152(6):1188-1202.
  23. Morano MT, Mesquita R, Da Silva GP, et al. Comparison of the effects of pulmonary rehabilitation with chest physical therapy on the levels of fibrinogen and albumin in patients with lung cancer awaiting lung resection: a randomized clinical trial. BMC Pulm Med. 2014; 14:121.
  24. Paneroni M, Simonelli C, Vitacca M, Ambrosino N. Aerobic exercise training in very severe chronic obstructive pulmonary disease: a systematic review and meta-analysis. Am J Phy Med Rehabil. 2017; 96(8):541-548.
  25. Ries AL, Make BJ, Lee SM, et al.; National Emphysema Treatment Trial Research Group. The effects of pulmonary rehabilitation in the national emphysema treatment trial. Chest. 2005; 128(6):3799-3809.
  26. Salhi B, Huysse W, Van Maele G, et al. The effect of radical treatment and rehabilitation on muscle mass and strength: a randomized trial in stages I-III lung cancer patients. Lung Cancer. 2014; 84(1):56-61.
  27. San Pedro GS. Pulmonary rehabilitation for the patient with severe chronic obstructive pulmonary disease. Am J Med Sci. 1999; 318(2):99-102.
  28. von Leupoldt A, Hahn E, Taube K, et al. Effects of 3-week outpatient pulmonary rehabilitation on exercise capacity, dyspnea, and quality of life in COPD. Lung. 2008; 186(6):387-391.
  29. Waterhouse JC, Walters SJ, Oluboyede Y, Lawson RA. A randomised 2 x 2 trial of community versus hospital pulmonary rehabilitation, followed by telephone or conventional follow-up. Health Technol Assess. 2010; 14(6):i-v, vii-xi, 1-140.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Agency for Healthcare Quality and Research. Pulmonary rehabilitation for COPD and other lung diseases. November 21, 2006. Available at: http://www.cms.gov/Medicare/Coverage/DeterminationProcess/‌downloads/id43TA.pdf. Accessed on April 24, 2018.
  2. American Association for Respiratory Care (AARC). AARC clinical practice guideline: pulmonary rehabilitation. Dallas (TX): American Association for Respiratory Care (AARC); 2002. Available at http://www.rcjournal.com/cpgs/prcpg.html. Accessed on April 24, 2018.
  3. American College of Chest Physicians and Canadian Thoracic Society. Guidelines: Prevention of acute exacerbations of COPD. 2016. Available at: http://journal.chestnet.org/article/S0012-3692(15)38941-8/abstract. Accessed on April 24, 2018.
  4. Guideline American Thoracic Society. Guidelines for Health Professionals: COPD. Available at: https://www.thoracic.org/statements/copd.php. Accessed on April 24, 2018.
    • Components of Pulmonary Rehabilitation
    • Principles of Pulmonary Rehabilitation
    • Outcomes from Pulmonary Rehabilitation
  5. Centers for Medicare and Medicaid Services. National Coverage Determination. Available at http://www.cms.hhs.gov/mcd/index_list.asp?list_type=ncd. Accessed April 24, 2018.
    • Lung Volume Reduction Surgery (Reduction Pneumoplasty). NCD #240.1. Effective November 17, 2005.
    • Pulmonary Rehabilitation. NCD #240.8. Effective September 25, 2007.
  6. Collins EG, Bauldoff G, Carlin B, et al. Clinical competency guidelines for pulmonary rehabilitation professionals: position statement of the American Association of Cardiovascular and Pulmonary Rehabilitation. J Cardiopulm Rehabil Prev. 2014; 34(5):291-302.
  7. Dowman L, Hill CJ, Holland AE. Pulmonary rehabilitation for interstitial lung disease. Cochrane Database Syst Rev. 2014;(10):CD006322.
  8. McCarthy B, Casey D, Devane D et al. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2015;(2):CD003793.
  9. Nici L, Donner C, Woulters E, et al. American Thoracic Society/European Respiratory Society Statement on Pulmonary Rehabilitation. Am J Respir Crit Care Med. 2006; 173(12):1390-1413. Available at: http://www.thoracic.org/statements/resources/respiratory-disease-adults/atserspr0606.pdf. Accessed on April 24, 2018.
  10. Parshall MB, Schwartzstein RM, Adams L, et al.; American Thoracic Society Committee on Dyspnea. An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. Am J Respir Crit Care Med. 2012; 185(4):435-452.
  11. Puhan MA, Gimeno-Santos E, Scharplatz M, et al. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Data Syst Rev. 2016;(10):CD005305.
  12. Qaseem A, Wilt TJ, Weinberger SE, et al.; American College of Physicians; American College of Chest Physicians; American Thoracic Society; European Respiratory Society. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med. 2011; 155(3):179-191.
  13. Ries AL, Bauldoff GS, Carlin BW, et al. Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines. Chest. 2007; 131(5 Suppl):4S-42S.
  14. Rochester CL, Vogiatzis I, Holland AE, et al. An Official American Thoracic Society/European Respiratory Society Policy Statement: Enhancing implementation, use, and delivery of pulmonary rehabilitation. Am J Respir Crit Care Med. 2015; 192(11):1373-1386.
  15. United States Department of Veterans Affairs/Department of Defense. VA/DoD clinical practice guidelines for the management of chronic obstructive pulmonary disease. December 2014. Available at: http://www.healthquality.va.gov/guidelines/CD/copd/VADoDCOPDCPG2014.pdf. Accessed on April 24, 2018.
  16. Wedzicha JA, Miravitlles M, Hurst JR, et al. Management of COPD exacerbations: a European Respiratory Society/American Thoracic Society guideline. Eur Respir J. 2017; 49(3).
Index

Asthma
Bronchiectasis
Chronic Bronchitis
Chronic Obstructive Pulmonary Disease
Chronic Respiratory Impairment
Cystic Fibrosis
Emphysema
Lung Transplantation
Lung Volume Reduction
Post-Polio Syndrome
Pulmonary Rehabilitation

History

Status

Date

Action

Reviewed

07/26/2018

Medical Policy & Technology Assessment (MPTAC) review. The document header wording updated from “Current Effective Date” to “Publish Date.” Discussion/General Information and References sections updated.

Reviewed

08/03/2017

MPTAC review. Updated Discussion/General Information and References section.

Reviewed

08/04/2016

MPTAC review. Updated Reference section. Removed ICD-9 codes from Coding section.

Revised

08/06/2015

MPTAC review. Reformatted criteria. Updated Background/Overview and References sections.

Reviewed

08/14/2014

MPTAC review. Updated Discussion/General Information and References sections.

Reviewed

08/08/2013

MPTAC review. Updated reference section.

Reviewed

08/09/2012

MPTAC review. Updated reference section.

Reviewed

08/18/2011

MPTAC review.

Reviewed

08/19/2010

MPTAC review.

 

01/01/2010

Updated coding section with 01/01/2010 HCPCS changes.

Reviewed

08/27/2009

MPTAC review.

Reviewed

08/28/2008

MPTAC review.

 

11/05/2007

Updated Reference section. Added 2007 ACCP/AACVPR recommendations.

Revised

08/23/2007

MPTAC review. Removed “superimposed cardiac disease” from medically necessary section. Updated reference section. Coding updated; removed HCPCS G0110-G0116 deleted 12/31/2005.

Reviewed

09/14/2006

MPTAC review. Updated references.

 

11/21/2005

Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).

Revised

09/22/2005

MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.

Pre-Merger Organizations

Last Review Date

Document Number

Title

 

Anthem MidWest

 

 

RA-010

Pulmonary Rehab in Acute Inpatient Rehabilitation Setting

Anthem West

 

UMR.016

Pulmonary Rehabilitation

Anthem SouthEast

 

Memo 1121

Pulmonary Rehabilitation

Anthem New Hampshire

 

 

Pulmonary Rehabilitation

WellPoint Health Networks, Inc.

04/28/2005

2.05.10

Pulmonary Rehabilitation (Outpatient)