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Number: 0021

Policy

*Please see amendment for Pennsylvania Medicaid at the

end of this CPB.

Aetna considers outpatient cardiac rehabilitation medically

necessary as described below.

The following selection criteria represent implementation of

guidelines established by the American College of Physicians,

the American College of Cardiology, and the Agency for

Healthcare Research and Quality (AHRQ) Health Technology

Assessment.

Last Review 10/27/2016

Effective: 07/31/1995

Next Review: 01/13/2017

Review History

Definitions

Eligibility:

Aetna considers a medically supervised outpatient Phase II

cardiac rehabilitation program medically necessary for selected

members when it is individually prescribed by a

physician within a 12‐month window after any of the following:

Clinical Policy Bulletin Notes

1. Acute myocardial infarction; or

2. Chronic stable angina pectoris unresponsive to medical

therapy which prevents the member from functioning

optimally to meet domestic or occupational needs

(particularly with modifiable coronary risk factors or poor

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exercise tolerance); or

3. Coronary artery bypass grafting (coronary bypass surgery,

CABG); or

4. Heart transplantation or heart‐lung transplantation; or

5. Major pulmonary surgery, great vessel surgery, or MAZE

arrhythmia surgery; or

6. Percutaneous coronary vessel remodeling (i.e., angioplasty,

atherectomy, stenting); or

7. Placement of a ventricular assist device; or

8. Sustained ventricular tachycardia or fibrillation, or survivors

of sudden cardiac death; or

9. Valve replacement or repair; or

10. Stable congestive heart failure (CHF) with left ventricular

ejection fraction (LVEF) 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; stable CHF

is defined as CHF in persons who have not had recent (less

than or equal to 6 weeks) or planned (less than or equal to 6

months) major cardiovascular hospitalizations or

procedures.

Cardiac rehabilitation programs are not recommended and are

considered experimental and investigational for individuals with

coronary artery disease (CAD) who have the following

conditions:

Acute pericarditis or myocarditis; or

Acute systemic illness or fever; or

Forced expiratory volume less than 1 liter; or

Moderate to severe aortic stenosis; or

New‐onset atrial fibrillation; or

Progressive worsening of exercise tolerance or dyspnea at

rest or on exertion over the previous 3 to 5 days; or

Recent embolism or thrombophlebitis; or

Significant ischemia at low work rates (less than 2 METs, or

metabolic equivalents); or

Third‐degree heart block without pacemaker; or

Uncontrolled diabetes.

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Aetna considers cardiac rehabilitation experimental and

investigational for all other indications (e.g., individuals who are

too debilitated to exercise, postural tachycardia syndrome, and

secondary prevention after transient ischemic attack or mild,

non‐disabling stroke) because of insufficient evidence in the

peer‐reviewed literature.

Frequency and Duration

The medically necessary frequency and duration of cardiac

rehabilitation is determined by the member’s level of cardiac

risk stratification:

I. High‐risk members have any of the following:

Decrease in systolic blood pressure of 15 mm Hg or more

with exercise; or

Exercise test limited to less than or equal to 5 METS; or

Marked exercise‐induced ischemia, as indicated by either

anginal pain or 2 mm or more ST depression by

electrocardiography (ECG); or

Recent myocardial infarction (less than 6 months) which

was complicated by serious ventricular arrhythmia,

cardiogenic shock or CHF; or

Resting complex ventricular arrhythmia; or

Severely depressed left ventricular function (LVEF less

than 30 %); or

Survivor of sudden cardiac arrest; or

Ventricular arrhythmia appearing or increasing with

exercise or occurring in the recovery phase of stress

testing.

Program Description for High‐Risk Members:

36 sessions (e.g., 3 times per week for 12 weeks) of

supervised exercise with continuous telemetry

monitoring

Create an individual out‐patient exercise program that

can be self‐monitored and maintained

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Educational program for risk factor/stress reduction

If no clinically significant arrhythmia is documented

during the first 3 weeks of the program, the provider may

have the member complete the remaining portion

without telemetry monitoring.

II. Intermediate‐risk members have any of the following:

Exercise test limited to 6 to 9 METS; or

Ischemic ECG response to exercise of less than 2 mm of

ST depression; or

Uncomplicated myocardial infarction, coronary artery

bypass surgery, or angioplasty and has a post‐cardiac

event maximal functional capacity of 8 METS or less on

ECG exercise test.

Program Description for Intermediate‐Risk Members:

24 sessions or less of exercise training without

continuous ECG monitoring (see exit criteria below, as

some members may only require fewer than 3 weekly

visits and/or less than 8 weeks)*

Geared to define an ongoing exercise program that is

"self‐administered."

III. Low‐risk members have exercise test limited to greater than

9 METS

Program Description for Low‐Risk Members:

6 1‐hour sessions involving risk factor reduction

education and supervised exercise to show safety and

define a home program (e.g., 3 times per week for a total

of 2 weeks or 2 sessions per week for 3 weeks).

Aetna considers additional cardiac rehabilitation services

medically necessary based on the above‐listed criteria when

the member has any of the following conditions:

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1. Another cardiovascular surgery or angioplasty; or

2. Another documented myocardial infarction or extension of

initial infarction; or

3. New clinically significant coronary lesions documented by

cardiac catheterization; or

4. New evidence of ischemia on an exercise test, including

thallium scan.

* Supervision by a physician or other qualified health care

professional is of no proven value for non‐EKG monitored

cardiac rehabilitation and is therefore considered experimental

and investigational because of insufficient evidence in the peer‐

reviewed literature.

Note: Phase III and Phase IV cardiac rehabilitation programs (see

background section) are not covered under standard Aetna

benefit plans as these programs are considered educational and

training in nature. Education and training programs are

generally not covered under most Aetna benefit plans. Please

check benefit plan descriptions.

Background

Patients who have cardiovascular events are often functional in

society and employed prior to a cardiac event, and frequently

require only re‐entry into their former life pattern. Cardiac

rehabilitation serves this purpose by providing a supervised

program in the outpatient setting that involves medical

evaluation, an ECG‐monitored physical exercise program,

cardiac risk factor modification, education, and counseling.

Cardiac rehabilitation is designed to help individuals with

conditions such as heart or vascular disease return to a

healthier and more productive life. This includes individuals

who have had heart attacks, open heart surgery, stable angina,

vascular disease or other cardiac related health problems.

Traditionally, cardiac rehabilitation programs have been

classified into 4 phases, phase I to IV, representing a

progression from the hospital (phase I) to a medically

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supervised out‐patient program (phases II and III) to a

community or home‐based setting (phase IV). Phase I cardiac

rehabilitation begins in the hospital (inpatient) after

experiencing a heart attack or other major heart event. During

this phase, individuals receive education and nutritional

counseling to prepare them for discharge. Phase II outpatient

cardiac rehabilitation begins after leaving the hospital. As

described by the U.S. Public Health Service, it is a

comprehensive, long‐term program including medical

evaluation, prescribed exercise, cardiac risk factor modification,

education and counseling. Phase II refers to medically

supervised programs that typically begin one to three weeks

after discharge and provide appropriate electrocardiographic

monitoring. Phase III cardiac rehabilitation utilizes a supervised

program that encourages exercise and healthy lifestyle and is

usually performed at home or in a fitness center with the goal

of continuing the risk factor modification and exercise program

learned in phase II. Phase IV cardiac rehabilitation is based on

an indefinite exercise maintenance program. These programs

encourage a commitment to regular exercise and healthy habits

for risk factor modification to establish lifelong cardiovascular

fitness. Some programs combine phases III and IV.

Due to changes in hospital and health care practices, and the

need to accommodate patients at various stages of disease risk,

some have argued that the need for phase designation

becomes inappropriate, and that cardiac rehabilitation

programs can be more appropriately distinguished as inpatient,

outpatient or community/home‐based programs. Participation

within these programs is determined by appropriate risk

stratification in order to maximize health care resources and

patient benefit. Irrespective of the program, there should be

regular communication, in the form of progress reports,

between the program staff and the patient’s attending physician

(Ignaszewski and Lear, 1998).

Entry into such programs is based on the demonstrated

limitation of functional capacity on exercise stress testing, and

the expectation that medically supervised exercise training will

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improve functional capacity to a clinically significant degree.

The exercise test in cardiac rehabilitation is a vital component

of the overall rehabilitative process as it provides continuous

follow‐up in a noninvasive manner and adds information to the

overall physical evaluation. In general, testing is performed

before entering the cardiac rehabilitation exercise program, and

sequentially during the program to provide information on the

changes in cardiac status, prognosis, functional capacity, and

evidence of training effect. The central component of cardiac

rehabilitation is a prescribed regimen of physical exercises

intended to improve functional work capacity and to increase

the patient's confidence and well‐being. Depending on the

degree of debilitation, cardiac patients may or may not require

a full or supervised rehabilitation program.

The scientific literature documents that some of the benefits of

participation in a cardiac rehabilitation program include

decreased symptoms of angina pectoris, dyspnea, and fatigue,

and improvement in exercise tolerance, blood lipid levels, and

psychosocial well‐being, as well as a reduction in weight,

cigarette smoking and stress. The efficacy of modification of

risk factors in reducing the progression of coronary artery

disease and future morbidity and mortality has been

established. Meta‐analysis of data from random controlled

studies indicates a 20 % to 25 % reduction in mortality in

patients participating in cardiac rehabilitation following

myocardial infarction as compared to controls.

The typical model for delivering outpatient cardiac

rehabilitation in the United States is for patients to attend

sessions 2 to 3 times per week for up to 12 to 18 weeks (36

total sessions) (CMS, 2006). A session typically lasts for

approximately 1 hour and includes aerobic and/or resistance

exercises with continuous electro‐cardiographic monitoring.

There are alternative approaches to this typical model. Patients

can be classified as low‐, moderate‐ or high‐risk for

participating in exercise based on a combination of clinical and

functional data. The number of recommended supervised

exercise sessions varies by risk level: low‐risk patients receive 6

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to 18 exercise sessions over 30 days or less from the date of the

cardiac event/procedure; moderate‐risk 12 to 24 sessions over

60 days; and high‐risk 18 to 36 sessions over 90 days (Hamm,

2008; AACVPR, 2004).

There is limited evidence on the appropriate duration of cardiac

rehabilitation. Hammill et al (2010) stated that for patients

with coronary heart disease, exercise‐based cardiac

rehabilitation improves survival rate and has beneficial effects

on risk factors for coronary artery disease. However, the

relationship between the number of sessions attended and

long‐term outcomes is unknown. In a national 5 % sample of

Medicare beneficiaries, these investigators identified 30,161

elderly patients who attended at least 1 cardiac rehabilitation

session between January 1, 2000, and December 31,

2005. They used a Cox proportional hazards model to estimate

the relationship between the number of sessions attended and

death and myocardial infarction (MI) at 4 years. The cumulative

number of sessions was a time‐dependent co‐variate. After

adjustment for demographical characteristics, co‐morbid

conditions, and subsequent hospitalization, patients who

attended 36 sessions had a 14 % lower risk of death (hazard

ratio [HR], 0.86; 95 % confidence interval [CI]: 0.77 to 0.97) and

a 12 % lower risk of MI (HR, 0.88; 95 % CI: 0.83 to 0.93) than

those who attended 24 sessions; a 22 % lower risk of death (HR,

0.78; 95 % CI: 0.71 to 0.87) and a 23 % lower risk of MI (HR,

0.77; 95 % CI: 0.69 to 0.87) than those who attended 12

sessions; and a 47 % lower risk of death (HR, 0.53; 95 % CI: 0.48

to 0.59) and a 31 % lower risk of MI (HR, 0.69; 95 % CI: 0.58 to

0.81) than those who attended 1 session. The authors

concluded that among Medicare beneficiaries, a strong dose‐

response relationship existed between the number of cardiac

rehabilitation sessions and long‐term outcomes.

Attending all 36 sessions reimbursed by Medicare was

associated with lower risks of death and MI at 4 years

compared with attending fewer sessions.

Prior and colleagues (2011) tested feasibility and effectiveness

of 6‐month outpatient comprehensive cardiac rehabilitation

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(CCR) for secondary prevention after transient ischemic attack

or mild, non‐disabling stroke. Consecutive consenting subjects

having sustained a transient ischemic attack or mild, non‐

disabling stroke within the previous 12 months (mean of

11.5 weeks; event‐to‐CCR entry) with greater than or equal to 1

vascular risk factor, were recruited from a stroke prevention

clinic providing usual care. These researchers measured 6‐

month CCR outcomes following a prospective cohort design. Of

110 subjects recruited from January 2005 to April 2006, 100

subjects (mean age of 64.9 years; 46 women) entered and 80

subjects completed CCR. These investigators obtained

favorable, significant intake‐to‐exit changes in: aerobic capacity

(+31.4 %; p < 0.001), total cholesterol (‐0.30 mmol/L; p =

0.008), total cholesterol/high‐density lipoprotein (‐11.6 %; p <

0.001), triglycerides (‐0.27 mmol/L; p = 0.003), waist

circumference (‐2.44 cm; p < 0.001), body mass index (‐0.53

kg/m(2); p = 0.003), and body weight (‐1.43 kg; p = 0.001). Low‐

density lipoprotein (‐0.24 mmol/L), high‐density lipoprotein

(+0.06 mmol/L), systolic (‐3.21 mm Hg) and diastolic (‐2.34 mm

Hg) blood pressure changed favorably, but non‐significantly. A

significant shift toward non‐smoking occurred (p = 0.008).

Compared with intake, 11 more individuals (25.6 % increase)

finished CCR in the lowest‐ mortality risk category of the Duke

Treadmill Score (p < 0.001). The authors concluded that CCR is

feasible and effective for secondary prevention after transient

ischemic attack or mild, non‐disabling stroke, offering a

promising model for vascular protection across chronic disease

entities. The authors stated that they know of no similar

previous investigation, and are now conducting a randomized

trial.

Pack et al (2013) noted that outpatient CR decreases mortality

rates but is under‐utilized. Current median time from hospital

discharge to enrollment is 35 days. These researchers

hypothesized that an appointment within 10 days would

improve attendance at CR orientation. At hospital discharge,

148 patients with a non‐surgical qualifying diagnosis for CR

were randomized to receive a CR orientation appointment

either within 10 days (early) or at 35 days (standard). The

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primary end‐point was attendance at CR orientation. Secondary

outcome measures were attendance at greater than or equal to

1 exercise session, the total number of exercise sessions

attended, completion of CR, and change in exercise training

work‐load while in CR. Average age was 60 ± 12 years; 56 % of

participants were male and 49 % were black, with balanced

baseline characteristics between groups. Median time (95 % CI)

to orientation was 8.5 (7 to 13) versus 42 (35 to NA [not

applicable]) days for the early and standard appointment

groups, respectively (p < 0.001). Attendance rates at the

orientation session were 77 % (57/74) versus 59% (44/74) in

the early and standard appointment groups, respectively, which

demonstrated a significant 18 % absolute and 56 % relative

improvement (relative risk, 1.56; 95 % CI: 1.03 to 2.37; p =

0.022). The number needed to treat was 5.7. There was no

difference (p > 0.05) in any of the secondary outcome

measures, but statistical power for these end points was low.

Safety analysis demonstrated no difference between groups in

CR‐related adverse events. The authors concluded that early

appointments for CR significantly improved attendance at

orientation. This simple technique could potentially increase

initial CR participation nationwide.

In a retrospective cohort study, Beauchamp et al (2013)

examined if attendance at CR independently predicts all‐cause

mortality over 14 years and whether there is a dose‐response

relationship between the proportion of CR sessions attended

and long‐term mortality. The sample comprised 544 men and

women eligible for CR following MI, coronary artery bypass

surgery or percutaneous interventions. Participants were

tracked 4 months after hospital discharge to ascertain CR

attendance status. Main outcome measure was all‐cause

mortality at 14 years ascertained through linkage to the

Australian National Death Index. In total, 281 (52 %) men and

women attended at least 1 CR session. There were few

significant differences between non‐attenders and attenders.

After adjustment for age, sex, diagnosis, employment, diabetes

and family history, the mortality risk for non‐attenders was 58

% greater than for attenders (HR = 1.58, 95 % CI: 1.16 to 2.15).

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Participants who attended less than 25 % of sessions had a

mortality risk more than twice that of participants attending

greater than or equal to 75 % of sessions (OR = 2.57, 95 % CI:

1.4 to 6.38). This association was attenuated after adjusting

for current smoking (OR = 2.06, 95 % CI: 0.80 to 5.29). The

authors concluded that this study provided further evidence for

the long‐term benefits of CR in a contemporary, heterogeneous

population. While a dose‐response relationship may exist

between the number of sessions attended and long‐term

mortality, this relationship does not occur independently of

smoking differences. They stated that CR practitioners should

encourage smokers to attend CR and provide support for

smoking cessation.

The Centers for Medicare & Medicaid Services (CMS, 2014) has

determined that the evidence is sufficient to expand coverage

for 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. Stable patients are defined

as patients who have not had recent (less than or equal to 6

weeks) or planned (less than or equal to 6 months) major

cardiovascular hospitalizations or procedures.

Shibata et al (2012) stated that recent studies have suggested

the presence of cardiac atrophy as a key component of the

pathogenesis of the postural orthostatic tachycardia syndrome

(POTS), similar to physical deconditioning. It has also been

shown that exercise intolerance is associated with a reduced

stroke volume (SV) in POTS, and that the high heart rate

observed at rest and during exercise in these patients is due to

this low SV. These researchers tested the hypotheses that (i)

circulatory control during exercise is normal in POTS; and (ii)

that physical “reconditioning” with exercise training improves

exercise performance in patients with POTS. A total of 19 (18

women) POTS patients completed a 3 month training program.

Cardiovascular responses during maximal exercise testing were

assessed in the upright position before and after training.

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Resting left ventricular diastolic function was evaluated by

Doppler echocardiography. Results were compared with those

of 10 well‐matched healthy sedentary controls. A lower SV

resulted in a higher heart rate in POTS at any given oxygen

uptake (V(O(2))) during exercise while the cardiac output (Q(c))‐

V(O(2)) relationship was normal. V(O(2peak)) was lower in

POTS than controls (26.1 ± 1.0 (SEM) versus 36.3 ± 0.9 ml kg‐1

min‐1; p < 0.001) due to a lower peak SV (65 ± 3 versus 80 ± 5

ml; p = 0.009). V(O(2peak)) increased by 11 % (p < 0.001) due

to increased peak SV (p = 0.021) and was proportional to total

blood volume. Peak heart rate was similar, but heart rate

recovery from exercise was faster after training than before

training (p = 0.036 for training and 0.009 for interaction).

Resting diastolic function was mostly normal in POTS before

training, though diastolic suction was impaired (p = 0.023).

There were no changes in any Doppler index after training. The

authors concluded that these results suggested that short‐term

exercise training improves physical fitness and cardiovascular

responses during exercise in patients with POTS.

Benarroch (2012) noted that management of POTS includes

avoidance of precipitating factors, volume expansion, physical

counter‐maneuvers, exercise training, pharmacotherapy

(fludrocortisone, midodrine, beta‐blockers, and/or

pyridostigmine), and behavioral‐cognitive therapy.

Although it can be argued that a structured exercise program

for physical reconditioning may be beneficial for patients with

POTS, it is unclear there is a need for a supervised cardiac

rehabilitation program. Furthermore, an UpToDate review on

“Postural tachycardia syndrome” (Freeman and Kaufman, 2014)

does not mention cardiac rehabilitation as a management tool.

Gaalema et al (2015) noted that continued smoking after a

cardiac event greatly increases mortality risk. Smoking

cessation and participation in CR are effective in reducing

morbidity and mortality. However, these 2 behaviors may

interact; those who smoke may be less likely to access or

complete CR. These researchers explored the association

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between smoking status and CR referral, attendance, and

adherence. They carried out a systematic literature search

examining associations between smoking status and CR referral,

attendance and completion in peer‐reviewed studies published

through July 1, 2014. For inclusion, studies had to report data

on outpatient CR referral, attendance or completion rates and

smoking status had to be considered as a variable associated

with these outcomes. A total of 56 studies met inclusion

criteria. A history of smoking was associated with an increased

likelihood of referral to CR. However, smoking status also

predicted not attending CR and was a strong predictor of CR

drop‐out. The authors concluded that continued smoking after

a cardiac event predicts lack of attendance in, and completion

of CR. The issue of smoking following a coronary event

deserves renewed attention.

Huang et al (2015) examined the effectiveness of telehealth

intervention‐delivered CR compared with center‐based

supervised CR. Medline, Embase, the Cochrane Central

Register of Controlled Trials (CENTRAL) in the Cochrane Library

and the Chinese BioMedical Literature Database (CBM), were

searched to April 2014, without language restriction. Existing

randomized controlled trials (RCTs), reviews, relevant

conference lists and gray literature were checked. Randomized

controlled trials that compared telehealth intervention

delivered CR with traditional center‐based supervised CR in

adults with CAD were included. Two reviewers selected studies

and extracted data independently. Main clinical outcomes

including clinical events, modifiable risk factors or other end‐

points were measured. A total of 15 articles reporting 9 trials

were reviewed, most of which recruited patients with MI or re‐

vascularization. No statistically significant difference was

found between telehealth interventions delivered and center‐

based supervised CR in exercise capacity (standardized mean

difference (SMD) ‐0.01; 95 % CI: ‐0.12 to 0.10), weight (SMD ‐

0.13; 95 % CI: ‐0.30 to 0.05), systolic and diastolic blood

pressure (SBP and DBP) (mean difference (MD) ‐1.27; 95 % CI:

‐3.67 to 1.13 and MD 1.00; 95 % CI: ‐0.42 to 2.43, respectively),

lipid profile, smoking (risk ratio (RR) 1.03; 95 % CI: 0.78 to 1.38),

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mortality (RR 1.15; 95 % CI: 0.61 to 2.19), quality of life and

psychosocial state. The authors concluded that telehealth

intervention‐delivered CR does not have significantly inferior

outcomes compared to center‐based supervised program in

low‐to‐moderate risk CAD patients. Telehealth intervention

offers an alternative deliver model of CR for individuals less able

to access center‐based CR. Choices should reflect preferences,

anticipation, risk profile, funding, and accessibility to health

service.

In a Cochrane review, Taylor et al (2015) compared the effect of

home‐based and supervised center‐based CR on mortality and

morbidity, health‐related quality of life, and modifiable cardiac

risk factors in patients with heart disease. To update searches

from the previous Cochrane review, these investigators

searched the Cochrane Central Register of Controlled Trials

(CENTRAL, The Cochrane Library, Issue 9, 2014), MEDLINE

(Ovid, 1946 to Week 1 of October, 2014), EMBASE (Ovid, 1980

to Week 41 of 2014), PsycINFO (Ovid, to Week 2 of October,

2014), and CINAHL (EBSCO, to October 2014). They checked

reference lists of included trials and recent systematic reviews.

No language restrictions were applied. The authors concluded

that this updated review supports the conclusions of the

previous version of this review that home‐ and center‐based

forms of CR seem to be equally effective for improving the

clinical and health‐related quality of life outcomes in low risk

patients after MI or re‐vascularization, or with HF. This finding,

together with the absence of evidence of important differences

in healthcare costs between the 2 approaches, supports the

continued expansion of evidence‐based, home‐based CR

programs. The choice of participating in a more traditional and

supervised center‐based program or a home‐based program

should reflect the preference of the individual patient. They

stated that further data are needed to determine whether the

effects of home‐ and center‐based CR reported in these short‐

term trials can be confirmed in the longer term. A number of

studies failed to give sufficient detail to assess their risk of bias.

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Appendix

Note on Exit Criteria

The following clinical exit criteria have been identified as

acceptable (CMS, 1989):

Symptoms of angina or dyspnea are stable at the patients

maximum exercise level; and

The patient has achieved a stable level of exercise tolerance

without ischemia or dysrhythmia; and

The patient's resting blood pressure and heart rate are

within normal limits; and

The stress test is not positive during exercise (A positive

stress test in this context implies an ECG with a junctional

depression of 2 mm or more associated with slowly rising,

horizontal, or down sloping ST segment).

CPT Codes / HCPCS Codes / ICD‐10 Codes

Informa'tion in the [brackets] below has been added for

clarifica'tion purposes. Codes requiring a 7th character are

represented by "+":

CPT codes covered if selection criteria are met:

93798 Physician or other qualified health care professional

services for outpatient cardiac rehabilitation; with

continuous ECG monitoring (per session) [not

covered for Phase III or Phase IV]

CPT codes not covered for indications listed in the CPB:

93797 Physician or other qualified health care professional

services for outpatient cardiac rehabilitation; without

continuous ECG monitoring (per session)

Other CPT codes related to the CPB:

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93015‐ Cardiovascular stress test using maximal or

93024 submaximal treadmill or bicycle exercise, continuous

electrocardiographic monitoring, and/or

pharmacological stress; with physician supervision,

with interpretation and report, or physician

supervision only, without interpretation and report,

or tracing only, without interpretation and report, or

interpretation and report only

HCPCS codes covered if selection criteria are met:

G0422 Intensive cardiac rehabilitation; with or without

continuous ECG monitoring with exercise, per session

[Ornish Cardiac Rehab Program] [not covered

for Phase III or Phase IV]

G0423 Intensive cardiac rehabilitation; with or without

continuous ECG monitoring; without exercise, per

session [not covered for Phase III or Phase IV]

S9472 Cardiac rehabilitation program, non‐physician

provider, per diem [not covered for Phase III or Phase

IV]

Other HCPCS codes related to the CPB:

S9449 Weight management classes, non‐physician provider,

per session

S9451 Exercise classes, non‐physician provider, per session

S9452 Nutrition classes, non‐physician provider, per session

S9453 Smoking cessation classes, non‐physician provider,

per session

S9454 Stress management classes, non‐physician provider,

per session

S9470 Nutritional counseling, dietitian visit

ICD‐10 codes covered if selection criteria are met:

I02.0 Rheumatic chorea with heart involvement

I05.0 ‐ I05.9, Rheumatic mitral, aortic, tricuspid, and multiple

I06.1 ‐ I08.9 valve diseases

I09.81 Rheumatic heart failure (congestive)

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I11.0 Hypertensive heart disease with heart failure

I13.0 Hypertensive heart and chronic kidney disease with

heart failure and stage 1 through stage 4, chronic

kidney disease, or unspecified chronic kidney disease

I13.2 Hypertensive heart and chronic kidney disease with

heart failure and stage 5 chronic kidney disease or

end stage renal disease

I20.9 Angina pectoris, unspecified [stable]

I21.01 ‐

I25.9

Ischemic heart disease

I34.0 ‐ I34.9,

I36.0 ‐ I37.9

Nonrheumatic mitral, tricuspid and pulmonary valve

disorders

I42.3 ‐ I42.7 Cardiomyopathy

I46.2 ‐ I46.9 Cardiac arrest

I47.2 Ventricular tachycardia

I47.9 Paroxysmal tachycardia, unspecified

I49.01 Ventricular fibrillation

I49.02 Ventricular flutter

I50.1 ‐ I50.9 Heart failure

I97.0,

I97.110,

I97.130,

I97.190

Postprocedural cardiac functional disturbances

Z51.89 Encounter for other specified aftercare

Z94.1 Heart transplant status

Z94.2 Lung transplant status

Z95.1 Presence of aortocoronary bypass graft

Z95.2 Presence of prosthetic heart valve

Z95.3 Presence of xenogenic heart valve

Z95.4 Presence of other heart‐valve replacement

Z95.5 Presence of coronary angioplasty implant and graft

Z95.811 Presence of heart assist device

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Z95.812 Presence of fully implantable artificial heart

Z98.61 Coronary angioplasty status

Z98.89 Other specified postprocedural status [surgery to

heart and great vessels]

ICD‐10 codes not covered for indications listed in the CPB (not

all‐inclusive):

E08.00 ‐

E13.9

Diabetes [uncontrolled]

I06.0 Rheumatic aortic stenosis [moderate to severe]

I30.0 ‐ I30.9 Acute pericarditis

I35.0 ‐ I35.9 Nonrheumatic aortic valve disorder [moderate to

severe stenosis]

I40.1 ‐ I40.9 Acute myocarditis

I44.2 Atrioventricular block, complete [without

pacemaker]

I48.0 ‐ I48.2,

I48.91

Atrial fibrillation [new onset]

I49.8 Other specified cardiac arrhythmias [postural

tachycardia syndrome]

I74.01 ‐

I74.9

Arterial embolism and thrombosis [recent]

I80.0 ‐ I80.9 Phlebitis and thrombophlebitis [recent]

Q23.0 Congenital stenosis of aortic valve [moderate to

severe]

Q23.3 Supravalvular aortic stenosis [moderate to severe]

R00.0 Tachycardia [postural]

R06.00 ‐

R06.09

Dyspnea [progressive worsening at rest or on

exertion over the previous three to five days]

R06.89 Other abnormalities of breathing [forced expiratory

volume of less than one liter]

R50.81 Fever presenting with conditions classified elsewhere

[systemic]

R50.9 Fever, unspecified [systemic]

19 of 30

The above policy is based on the following references:

1. Dinnes J, Kleijnen J, Leitner M, et al. Cardiac

rehabilitation. Qual Health Care. 1999;8(1):65‐71.

2. Thompson DR, De Bono DP. How valuable is cardiac

rehabilitation and who should get it? Heart.

1999;82(5):545‐546.

3. Kobashigawa JA. Postoperative management following

heart transplantation. Transplant Proc.

1999;31(5):2038‐2046.

4. Ades PA, Savage PD, Poehlman ET, et al. Lipid lowering in

the cardiac rehabilitation setting. J Cardiopulm Rehabil.

1999;19(4):255‐260.

5. Ceci V, Chieffo C, Giannuzzi P, et al. Standards and

guidelines for cardiac rehabilitation. Working Group on

Cardiac Rehabilitation of the European Society for

Cardiology. Cardiologia. 1999;44(6):579‐584.

6. Lavie CJ, Milani RV. Effects of cardiac rehabilitation and

exercise training on peak aerobic capacity and work

efficiency in obese patients with coronary artery disease.

Am J Cardiol. 1999;83(10):1480‐1483, A7.

7. Paul‐Labrador M, Vongvanich P, Merz CN. Risk

stratification for exercise training in cardiac patients: Do

the proposed guidelines work? J Cardiopulm Rehabil.

1999;19(2):118‐125.

8. Blackwood R. Cardiac rehabilitation. Curr Opin Cardiol.

1990;5(4):502‐507.

9. Kobashigawa JA, Leaf DA, Lee N, et al. A controlled trial of

exercise rehabilitation after heart transplantation

[published erratum appears in N Engl J Med.

1999;340(12):976] N Engl J Med. 1999;340(4):272‐277.

Z86.73 Personal history of transient ischemic attack [TIA],

and cerebral infarction without residual deficits [not

covered when used to report secondary prevention

after transient ischemic attack or mild, non‐disabling

stroke]

20 of 30

10. Fletcher GF. Current status of cardiac rehabilitation. Am

Fam Physician. 1998;58(8):1778‐1782.

11. Turner‐Boutle M, Dinnes J. On the evidence. Cardiac

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effectiveness of cardiac rehabilitation. Intensive Crit Care

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13. Limacher MC. Exercise and rehabilitation in women.

Indications and outcomes. Cardiol Clin.

1998;16(1):27‐36.

14. Peterson ED, Shaw LJ, Califf RM. Risk stratification after

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15. No authors listed. Physical activity and cardiovascular

health. NIH Consens Statement. 1995;13(3):1‐33.

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Health Care Policy and Research and the National Heart,

Lung, and Blood Institute; October 1995.

17. Thompson DR. Cardiac rehabilitation in the United

Kingdom: Guidelines and audit standards. National

Institute for Nursing, the British Cardiac Society and the

Royal College of Physicians of London. Heart.

1996;75(1):89‐93.

18. Fletcher GF. Statement on exercise: Benefits and

recommendations for physical activity programs for all

Americans. A statement for health professionals by the

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Council on Clinical Cardiology, American Heart

Association. Circulation. 1996;94(4):857‐862.

19. Verrill D. Recommended guidelines for monitoring and

supervision of North Carolina phase II/III cardiac

rehabilitation programs. A position paper by the North

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Cardiopulm Rehabil. 1996;16(1):9‐24.

20. Pina IL. Guidelines for clinical exercise testing

laboratories. A statement for healthcare professionals

from the Committee on Exercise and Cardiac

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Rehabilitation, American Heart Association. Circulation.

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21. Balady GJ, Fletcher BJ, Froelicher ES, et al. AHA

Medical/Scientific Statement. Cardiac Rehabilitation

Programs. Dallas, TX: American Heart Association (AHA);

1994.

22. Squires RW, Gau GT, Miller TD, et al. Cardiovascular

rehabilitation: Status, 1990. Mayo Clin Proc.

1990;65(5):749‐755.

23. Greenland P, Chu JS. Cardiac Rehabilitation Services:

Clinical Practice Guidelines. Philadelphia, PA: American

College of Physicians; 1994.

24. Hotta SS. Cardiac rehabilitation programs. Health

Technology Assessment Reports. AHCPR Pub. No. 92‐

0015. Rockville, MD: Agency for Healthcare Policy and

Research (AHCPR), Office of Health Technology

Assessment (OHTA); December 1991;3.

25. American College of Cardiology (ACC). Cardiovascular

Rehabilitation. ACC Position Statement. Bethesda, MD:

ACC; 1985:1‐6. Available at: http://www.acc.org/clinical

/position/72539.pdf. Accessed January 19, 2006.

26. Greenland P, Chu JS. Efficacy of cardiac rehabilitation

services. With emphasis on patients after myocardial

infarction. Ann Intern Med. 1988;109(8):650‐653.

27. Position paper of the American Association of

Cardiovascular and Pulmonary Rehabilitation: Scientific

evidence of the value of cardiac rehabilitation services

with emphasis on patients following myocardial infarction

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Cardiopulm Rehab. 1990;10:79‐87.

28. Fletcher GF. Current status of cardiac rehabilitation. Curr

Probl Cardiol. 1992;17(3):143 ‐203.

29. O'Connor GT, Buring JE, Yusuf S, et al. An overview of

randomized trials of rehabilitation with exercise after

myocardial infarction. Circulation. 1989;80(2):234‐244.

30. Oldridge N, Guyatt G, Jones N, et al. Effects on quality of

life with comprehensive rehabilitation after acute

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1089.

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31. Forman DE, Farquhar W. Cardiac rehabilitation and

secondary prevention programs for elderly cardiac

patients. Clin Geriatr Med. 2000;16(3):619‐629.

32. Ades PA, Coello CE. Effects of exercise and cardiac

rehabilitation on cardiovascular outcomes. Med Clin

North Am. 2000;84(1):251‐265, x‐xi.

33. Pasquali SK, Alexander KP, Peterson ED. Cardiac

rehabilitation in the elderly. Am Heart J.

2001;142(5):748‐755.

34. Ades PA. Cardiac rehabilitation and secondary prevention

of coronary heart disease. N Engl J Med.

2001;345(12):892‐902.

35. Balady GJ, Ades PA, Comoss P, et al. Core components of

cardiac rehabilitation/secondary prevention programs: A

statement for healthcare professionals from the

American Heart Association and the American

Association of Cardiovascular and Pulmonary

Rehabilitation Writing

Group. Circulation. 2000;102(9):1069‐1073.

36. Stone JA, Cyr C, Friesen M, et al. Canadian guidelines for

cardiac rehabilitation and atherosclerotic heart disease

prevention: A summary. Can J Cardiol. 2001;17 Suppl

B:3B‐30B.

37. Davison J. Factors that affect women's uptake of cardiac

rehabilitation schemes. Prof Nurse. 2002;17(11):682‐

685.

38. Cooper AF, Jackson G, Weinman J, Horne R. Factors

associated with cardiac rehabilitation attendance: A

systematic review of the literature. Clin

Rehabil. 2002;16(5):541‐552.

39. University of York. NHS Centre for Reviews and

Dissemination. Cardiac rehabilitation. Effective Health

Care. 1998;4(4):1‐12.

40. Ignaszewski A, Lear SA. Cardiac rehabilitation programs.

In: Canadian Cardiovascular Society 1998

Consensus Conference on the Prevention of

Cardiovascular Diseases: The Role of the Cardiovascular

Specialist. Ottawa, ON: Canadian Cardiovascular Society;

1998. Available at: http://www.ccs.ca/society

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25.asp. Accessed January 21, 2004.

41. Scottish Intercollegiate Guidelines Network (SIGN).

Cardiac rehabilitation. A national clinical guideline. SIGN

Publication No. 57. Edinburgh, Scotland: SIGN; January

2002.

42. New Zealand Guidelines Group (NZGG). Cardiac

rehabilitation. Evidence‐Based Best Practice Guideline.

Wellington, New Zealand: NZGG; August 2002.

43. Jolliffe JA, Rees K, Taylor RS, et al. Exercise‐based

rehabilitation for coronary heart disease. Cochrane

Database Syst Rev. 2001;(1):CD001800.

44. Rees K, Taylor RS, Singh S, et al. Exercise based

rehabilitation for heart failure. Cochrane Database Syst

Rev. 2004,(3):CD003331.

45. Stewart KJ, Badenhop D, Brubaker PH, et al. Cardiac

rehabilitation following percutaneous revascularization,

heart transplant, heart valve surgery, and for chronic

heart failure. Chest. 2003;123(6):2104‐2111.

46. Giannuzzi P, Saner H, Bjornstad H, et al. Secondary

prevention through cardiac rehabilitation: Position paper

of the Working Group on Cardiac Rehabilitation and

Exercise Physiology of the European Society of

Cardiology. Eur Heart J. 2003;24(13):1273‐1278.

47. National Institute for Clinical Excellence (NICE), North of

England Evidence‐based Guidelines Development Project.

Prophylaxis for patients who have experienced a

myocardial infarction: Drug treatment, cardiac

rehabilitation and dietary manipulation ‐ guideline.

Evidence‐based Clinical Practice Guideline. London, UK:

NICE; 2001.

48. Institute for Clinical Systems Improvement (ICSI). Cardiac

rehabilitation. Technology Assessment Report.

Bloomington, MN: ICSI; 2002.

49. Brown A, Noorani H, Taylor R, et al. A clinical and

economic review of exercise‐based cardiac rehabilitation

programs for coronary artery disease. Technology

Overview No. 11. Ottawa, ON: Canadian Coordinating

Office for Health Technology Assessment (CCOHTA);

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August 2003.

50. Gordon NF, Gulanick M, Costa F, et al. Physical activity

and exercise recommendations for stroke survivors: An

American Heart Association scientific statement from the

Council on Clinical Cardiology, Subcommittee on Exercise,

Cardiac Rehabilitation, and Prevention; the Council on

Cardiovascular Nursing; the Council on Nutrition, Physical

Activity, and Metabolism; and the Stroke Council.

Circulation. 2004;109(16):2031‐2041.

51. Taylor RS, Brown A, Ebrahim S, et al. Exercise‐based

rehabilitation for patients with coronary heart disease:

Systematic review and meta‐analysis of randomized

controlled trials. Am J Med. 2004;116:682–692.

52. Centers for Medicare and Medicaid Services

(CMS). Cardiac rehabilitation programs. National

Coverage Determination. Coverage Issues Manual Sec.

20.10. Baltimore, MD: CMS; effective August 1,

1989. Available at: http://www.cms.hhs.gov/mcd/

(http://www.cms.hhs.gov/mcd/). Accessed January 19,

2006.

53. Herridge ML, Stimler CE, Southard DR, et al. Depression

screening in cardiac rehabilitation: AACVPR Task Force

Report. J Cardiopulm Rehabil. 2005;25(1):11‐13.

54. Arnold JM, Liu P, Demers C, et al; Canadian Cardiovascular

Society. Canadian Cardiovascular Society consensus

conference recommendations on heart failure 2006:

Diagnosis and management. Can J Cardiol. 2006;22(1):23‐

45.

55. Jolly K, Taylor RS, Lip GY, Stevens A. Home‐based cardiac

rehabilitation compared with centre‐based rehabilitation

and usual care: A systematic review and meta‐analysis.

Int J Cardiol. 2006;111(3):343‐351.

56. Zwisler A‐D, Nissen NK, Madsen M; DANREHAB Group.

Cardiac rehabilitation ‐ a health technology assessment:

Evidence from the literature and the DANREHAB trial

[summary]. Copenhagen, Denmark: Danish Centre for

Evaluation and Health Technology Assessment

(DACEHTA); 2006.

57. Skinner JS, Cooper A, Feder GS; Guideline Development

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Group. Secondary prevention for patients following a

myocardial infarction: Summary of NICE guidance. Heart.

2007;93(7):862‐864.

58. Thomas RJ, King M, Lui K, et al; AACVPR; ACC; AHA;

American College of Chest Physicians; American College

of Sports Medicine; American Physical Therapy

Association; Canadian Association of Cardiac

Rehabilitation; European Association for Cardiovascular

Prevention and Rehabilitation; Inter‐American Heart

Foundation; National Association of Clinical Nurse

Specialists; Preventive Cardiovascular Nurses Association;

Society of Thoracic Surgeons. AACVPR/ACC/AHA 2007

performance measures on cardiac rehabilitation for

referral to and delivery of cardiac

rehabilitation/secondary prevention services endorsed by

the American College of Chest Physicians, American

College of Sports Medicine, American Physical Therapy

Association, Canadian Association of Cardiac

Rehabilitation, European Association for Cardiovascular

Prevention and Rehabilitation, Inter‐American Heart

Foundation, National Association of Clinical Nurse

Specialists, Preventive Cardiovascular Nurses Association,

and the Society of Thoracic Surgeons. J Am Coll Cardiol.

2007;50(14):1400‐1433.

59. National Institute for Health and Clinical Excellence

(NICE). Secondary prevention in primary and secondary

care for patients following a myocardial infarction. NICE

Clinical Guideline 48. London, UK: NICE; May 2007.

60. Centers for Disease Control and Prevention (CDC).

Receipt of outpatient cardiac rehabilitation among heart

attack survivors‐‐United States, 2005. MMWR Morb

Mortal Wkly Rep. 2008;57(4):89‐94.

61. Canyon S, Meshgin N. Cardiac rehabilitation ‐ reducing

hospital readmissions through community based

programs. Aust Fam Physician. 2008;37(7):575‐577.

62. Austin J, Williams WR, Ross L, Hutchison S. Five‐year

follow‐up findings from a randomized controlled trial of

cardiac rehabilitation for heart failure. Eur J Cardiovasc

Prev Rehabil. 2008;15(2):162‐167.

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63. American Association of Cardiovascular and Pulmonary

Rehabilitation (AACVPR). Guidelines for Cardiac

Rehabilitation and Secondary Prevention Programs. 4th

ed. Champaign, IL: Human Kinetics; 2004.

64. Hamm LF. Cardiac rehabilitation in the United States:

From evidence to application. Kardiol Pol.

2008;66:921‐924.

65. Centers for Medicare and Medicaid Services (CMS). NCD

for cardiac rehabilitation programs. Pub No. 100‐3,

section 20.10, version 2. Medicare Coverage Database.

Baltimore, MD: CMS; June 23, 2006.

66. Ueno A, Tomizawa Y. Cardiac rehabilitation and artificial

heart devices. J Artif Organs. 2009;12(2):90‐97.

67. Fernandez RS, Davidson P, Griffiths R, et al. A pilot

randomised controlled trial comparing a health‐related

lifestyle self‐management intervention with standard

cardiac rehabilitation following an acute cardiac event:

Implications for a larger clinical trial. Aust Crit Care.

2009;22(1):17‐27.

68. Hammill BG, Curtis LH, Schulman KA, Whellan DJ.

Relationship between cardiac rehabilitation and long‐

term risks of death and myocardial infarction among

elderly Medicare beneficiaries. Circulation.

2010;121(1):63‐70.

69. Taylor RS, Dalal H, Jolly K, et al. Home‐based versus

centre‐based cardiac rehabilitation. Cochrane Database

Syst Rev. 2010;(1):CD007130.

70. Davies EJ, Moxham T, Rees K, et al. Exercise based

rehabilitation for heart failure. Cochrane Database Syst

Rev. 2010;(4):CD003331.

71. Piepoli MF, Corrà U, Benzer W, et al; Cardiac

Rehabilitation Section of the European Association of

Cardiovascular Prevention and Rehabilitation. Secondary

prevention through cardiac rehabilitation: From

knowledge to implementation. A position paper from the

Cardiac Rehabilitation Section of the European

Association of Cardiovascular Prevention and

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72. American Association of Cardiovascular and Pulmonary

Rehabilitation; American College of Cardiology

Foundation; American Heart Association Task Force on

Performance Measures (Writing Committee to Develop

Clinical Performance Measures for Cardiac

Rehabilitation), Thomas RJ, King M, Lui K, et al.

AACVPR/ACCF/AHA 2010 Update: Performance Measures

on Cardiac Rehabilitation for Referral to Cardiac

Rehabilitation / Secondary Prevention Services Endorsed

by the American College of Chest Physicians, the

American College of Sports Medicine, the American

Physical Therapy Association, the Canadian Association of

Cardiac Rehabilitation, the Clinical Exercise Physiology

Association, the European Association for Cardiovascular

Prevention and Rehabilitation, the Inter‐American Heart

Foundation, the National Association of Clinical Nurse

Specialists, the Preventive Cardiovascular Nurses

Association, and the Society of Thoracic Surgeons. J Am

Coll Cardiol. 2010;56(14):1159‐1167.

73. Prior PL, Hachinski V, Unsworth K, et al. Comprehensive

cardiac rehabilitation for secondary prevention after

transient ischemic attack or mild stroke: I: Feasibility and

risk factors. Stroke. 2011;42(11):3207‐3213.

74. Balady GJ, Ades PA, Bittner VA, et al.; American Heart

Association Science Advisory and Coordinating

Committee. Referral, enrollment, and delivery of cardiac

rehabilitation/secondary prevention programs at clinical

centers and beyond: A presidential advisory from the

American Heart Association. Circulation.

2011;124(25):2951‐2960.

75. Isaksen K, Morken IM, Munk PS, Larsen AI. Exercise

training and cardiac rehabilitation in patients with

implantable cardioverter defibrillators: A review of

current literature focusing on safety, effects of exercise

training, and the psychological impact of programme

participation. Eur J Cardiovasc Prev Rehabil.

2012;19(4):804‐812.

76. Tikkanen AU, Oyaga AR, Riano OA, et al. Paediatric

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77. King M, Bittner V, Josephson R, et al. Medical director

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the American Association of Cardiovascular and

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Association. Circulation. 2012;126(21):2535‐2543.

78. Pack QR, Mansour M, Barboza JS, et al. An early

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hospital discharge improves attendance at orientation: A

randomized, single‐blind, controlled trial. Circulation.

2013;127(3):349‐355.

79. Beauchamp A, Worcester M, Ng A, et al. Attendance at

cardiac rehabilitation is associated with lower all‐cause

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2013;99(9):620‐625.

80. Centers for Medicare & Medicaid Services (CMS).

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chronic heart failure (CAG‐00437N). Medicare Coverage

Database. Baltimore, MD: CMS; February 18, 2014.

81. Centers for Medicare and Medicaid Services (CMS).

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rehabilitation programs for chronic heart failure

(20.10.1). Baltimore, MD: CMS; February 18, 2014.

82. Shibata S, Fu Q, Bivens TB, et al. Short‐term exercise

training improves the cardiovascular response to exercise

in the postural orthostatic tachycardia syndrome. J

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83. Benarroch EE. Postural tachycardia syndrome: A

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85. Gaalema DE, Cutler AY, Higgins S3, Ades PA. Smoking and

cardiac rehabilitation participation: Associations with

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86. Huang K, Liu W, He D, et al. Telehealth interventions

versus center‐based cardiac rehabilitation of coronary

artery disease: A systematic review and meta‐analysis.

Eur J Prev Cardiol. 2015;22(8):959‐971.

87. Taylor RS, Dalal H, Jolly K, et al. Home‐based versus

centre‐based cardiac rehabilitation. Cochrane Database

Syst Rev. 2015;8:CD007130.

88. Zwisler AD, Norton RJ, Dean SG, et al. Home‐based

cardiac rehabilitation for people with heart failure: A

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89. Sibilitz KL, Berg SK, Ta ng LH, et al. Exercise‐based cardiac

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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering

plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains

only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not

provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are

independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates.

Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy

Bulletin may be updated and therefore is subject to change.

Copyright © 2001‐2016 Aetna Inc.

AETNA BETTER HEALTH® OF PENNSYLVANIA

Amendment to Aetna Clinical Policy Bulletin Number: 0021

Cardiac Rehabilitation

There are no amendments for Medicaid.

www.aetnabetterhealth.com