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Clinical Policy Title: Pulmonary rehabilitation
Clinical Policy Number: 07.02.01
Effective Date: September 1, 2013
Initial Review Date: March 21, 2013
Most Recent Review Date: March 6, 2018
Next Review Date: March 2019
Related policies:
CP# 07.02.05 Noninvasive positive pressure ventilation in adults
CP# 07.02.06 Mechanical airway clearance devices
CP# 04.02.02 Cardiac rehabilitation
CP# 07.02.07 Lung transplants
CP# 07.03.03 Lung volume reduction surgery
ABOUT THIS POLICY: Select Health of South Carolina has developed clinical policies to assist with making coverage determinations. Select
Health of South Carolina’s clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peer-reviewed professional literature. These clinical policies along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including any state- or plan-specific definition of “medically necessary,” and the specific facts of the particular situation are considered by Select Health of South Carolina when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. Select Health of South Carolina’s clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their patients. Select Health of South Carolina’s clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, Select Health of South Carolina will update its clinical policies as necessary. Select Health of South Carolina’s clinical policies are not guarantees of payment.
Coverage policy
Select Health of South Carolina considers the use of pulmonary rehabilitation to be clinically proven and,
therefore, medically necessary when both criteria are met (Spruit, 2013; Qaseem, 2011; Ries, 2007 for
the American College of Chest Physicians and the American Association of Cardiovascular and
Pulmonary Rehabilitation [ACCP/AACVPR]):
For any of the following diagnoses:
- Asthma.
- Chronic obstructive pulmonary disease spirometric grades 2 – 4, as defined by the
Global Initiative for Chronic Obstructive Lung Disease (GOLD, 2018):
GOLD 2: Forced expiratory volume in one-second/forced vital capacity (FEV1
/ FVC) less than 0.7, and post-bronchodilator FEV1 greater than or equal to
50 percent to less than 80 percent predicted.
Policy contains:
Chronic pulmonary or lung
disease.
Lung transplantation.
Lung volume reduction surgery.
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GOLD 3: FEV1 / FVC less than 0.7, and FEV1 greater than or equal to 30
percent to less than 50 percent predicted.
GOLD 4: FEV1 / FVC less than 0.7, and FEV1 less than 30 percent predicted.
- Bronchiectasis.
- Cystic fibrosis.
- Interstitial lung disease (e.g., idiopathic pulmonary fibrosis).
- Obliterative bronchiolitis.
- Restrictive respiratory disease due to a neuromuscular disorder (e.g., amyotrophic
lateral sclerosis or Guillain-Barré).
- Sarcoidosis.
- Pre-and post-lung transplantation.
- Pre- and post-lung volume reduction surgery.
- Other documented severe pulmonary condition (e.g., lung resection for lung
cancer).
All of the following medical criteria:
- Dyspnea with rest or exertion.
- Limited physical activity and inability to perform activities of daily living.
- No contraindications to participating in a supervised exercise program.
- Capability to participate in the treatment plan (physically and cognitively).
Limitations:
All other uses of pulmonary rehabilitation are not medically necessary.
Pulmonary rehabilitation for members with mild chronic obstructive pulmonary disease (GOLD 1,
defined as FEV1 / FVC less than 0.7 and a post-bronchodilator FEV1 greater than or equal to 80 percent
predicted) is not medically necessary due to insufficient evidence supporting its use in this population
(Rugbjerg, 2015).
Pulmonary rehabilitation for the prevention of rehospitalizations in patients with chronic obstructive
pulmonary disease who have had an exacerbation greater than four weeks after a recent hospitalization
is not medically necessary due to insufficient evidence of effectiveness (Criner, 2015; Spruit, 2013).
Pulmonary rehabilitation should not be used in individuals unable to safely participate in an exercise
program.
Pulmonary rehabilitation services are generally provided in an outpatient setting.
For Medicare members only:
An individual may receive up to a lifetime maximum of 72 pulmonary rehabilitation sessions (Medicare
local coverage articles A52756 and A52770).
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Alternative covered services:
Physician services in the treatment of chronic pulmonary disease and medications as prescribed.
Background
Pulmonary disease is a major cause of morbidity and mortality. For example, chronic obstructive
pulmonary disease is the third leading cause of death in the United States, and mortality from the
disease is increasing (American Lung Association, 2017). Treatment of pulmonary diseases involves
arresting the underlying pathophysiology, such as removing the offending agent (e.g., smoking
cessation), and preventing and treating complications related to the lung disease (e.g., suppression of
bacterial infection). Other interventions are employed to address the disability associated with
pulmonary disease, one of which is pulmonary rehabilitation.
The American Thoracic Society/European Respiratory Society (ATS/ERS) defines pulmonary
rehabilitation as: “…a comprehensive intervention based on a thorough patient assessment followed by
patient tailored therapies that 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 to health-enhancing behaviors…” (Spruit, 2013). This
definition was updated from 2006 to emphasize the importance of changing behavior, as well as
stabilizing or reversing systemic manifestations of the disease.
The goals of pulmonary rehabilitation are to reduce levels of morbidity and to improve activity and
participation. Such programs are often started while an individual is an inpatient in a health care facility
and continued in an outpatient setting. Pulmonary rehabilitation programs may also benefit individuals
who are facing lung transplantation or lung volume reduction surgery by improving activity tolerance,
stabilizing disease progression, and assisting in therapeutic techniques employed after surgery.
Searches
Select Health of South Carolina searched PubMed and the databases of:
UK National Health Services Centre for Reviews and Dissemination.
Agency for Healthcare Research and Quality’s National Guideline Clearinghouse and other
evidence-based practice centers.
The Centers for Medicare & Medicaid Services (CMS).
We conducted searches on January 19, 2018. Search terms were: “pulmonary rehabilitation,”
“rehabilitation,” “Rehabilitation” (MeSH), and “Lung Diseases” (MeSH).
We included:
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Systematic reviews, which pool results from multiple studies to achieve larger sample sizes
and greater precision of effect estimation than in smaller primary studies. Systematic
reviews use predetermined transparent methods to minimize bias, effectively treating the
review as a scientific endeavor, and are thus rated highest in evidence-grading hierarchies.
Guidelines based on systematic reviews.
Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple
cost studies), reporting both costs and outcomes — sometimes referred to as efficiency
studies — which also rank near the top of evidence hierarchies.
Findings
Select Health of South Carolina identified several systematic reviews, a guideline developed by the
ACCP/AACVPR (Ries, 2007), and several economic studies for this policy. The success of pulmonary
rehabilitation stems from its favorable influence on systemic effects and comorbidities associated with
chronic lung disease. The preponderance of evidence has shown beneficial outcomes of pulmonary
rehabilitation in patients primarily with GOLD 2 to 4 chronic obstructive pulmonary disease who are
enrolled in hospital-based outpatient programs.
There is high-quality evidence that six to 12 weeks of pulmonary rehabilitation produces
benefits in several outcomes that decline gradually over 12 to 18 months, with the
exception of some benefits, such as health-related quality of life, that were sustained above
controls at 12 to 18 months. Other benefits include:
- Symptom improvement in dyspnea (high quality).
- Lower health care utilization (moderate quality).
- Psychosocial benefits (moderate quality).
There is low-quality, very low-quality, or insufficient evidence of effectiveness of
maintenance strategies on long-term outcomes or survival or of the cost effectiveness of
pulmonary rehabilitation.
There is high-quality evidence of effectiveness for including unsupported endurance training
of the upper extremities and strength training and exercise training of the lower extremity
muscles in pulmonary rehabilitation programs.
There is moderate-quality evidence of effectiveness for including education strategies
(collaborative self-management and prevention and treatment of exacerbations) and
noninvasive ventilation as an adjunct to exercise training in selected patients with severe
chronic obstructive pulmonary disease. Moderate-quality evidence argues against routine
use of inspiratory muscle training.
There is moderate-quality evidence of effectiveness of pulmonary rehabilitation for some
patients with chronic respiratory diseases other than chronic obstructive pulmonary
disease.
There is low-quality, very low-quality, or insufficient evidence of effectiveness for including
psychosocial interventions as a single therapeutic modality, supplemental oxygen during
exercise training in patients with severe exercise-induced hypoxemia, and nutritional
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supplementation in pulmonary rehabilitation programs. Supplemental oxygen may benefit
patients without exercise-induced hypoxemia to improve exercise endurance during high-
intensity exercise programs. For patients with chronic respiratory diseases other than
chronic obstructive pulmonary disease, modifications should include treatment strategies
specific to individual diseases and patients in addition to standard of care treatment
strategies.
According to the ATS/ERS, pulmonary rehabilitation should be considered for any patient with chronic
respiratory disease who has persistent symptoms or limited activity, or is unable to adjust to illness,
despite otherwise optimal medical management (Spruit, 2013). Evidence on the selection of patients
who might benefit is derived mostly from patients with chronic obstructive pulmonary disease, with a
growing number of studies describing rehabilitation in other chronic lung diseases (such as asthma,
bronchiectasis, and cystic fibrosis) that may benefit from an in-depth pulmonary rehabilitation program.
Gains can be achieved regardless of age, sex, lung function, or smoking status. Pulmonary rehabilitation
is generally considered a necessary component before and after lung volume reduction surgery and lung
transplantation (Spruit, 2013).
The optimal candidates are clinically stable and motivated to achieve the fullest benefit from pulmonary
rehabilitation. Data are limited on predictors of non-adherence, but predictors of reduced long-term
adherence include social isolation and continued smoking. Patients who are hypoxemic at rest or with
exercise should not be excluded from rehabilitation but should be provided with ambulatory oxygen
during the exercise sessions (Spruit, 2013).
Exclusion criteria include significant orthopedic or neurologic problems that reduce mobility or
cooperation with physical training. In addition, poorly controlled coexisting medical conditions,
especially psychiatric conditions or unstable cardiac disease, may limit participation, thereby making the
patient an unsuitable candidate (Spruit, 2013).
There is no consensus on the optimal number of sessions per week or the optimal duration of
pulmonary rehabilitation (Spruit, 2013). Outpatient programs commonly meet two or three days per
week, while inpatient programs are usually planned for five days per week. The session length per day is
generally one to four hours. The evidence suggests longer programs produce greater gains and
maintenance of benefits, with a minimum of eight weeks recommended to achieve a substantial effect.
While programs longer than 12 weeks have produced greater sustainable benefits than shorter
programs, improvement in functional exercise capacity seems to plateau within 12 weeks of the start of
the pulmonary rehabilitation program, despite continued training (Spruit, 2013).
Areas in need of further research include:
Optimizing the effectiveness of pulmonary rehabilitation, including defining the optimal
intensity and duration of exercise training and defining the effects of the non-exercise
components and the role of adjunctive therapies such as hormonal therapy, supplemental
oxygen administration to non-hypoxemic patients, and non-invasive ventilation.
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Identifying the predictors and rationale of non-adherence and non-participation to develop
effective strategies to engage participation and maintain the benefits of pulmonary
rehabilitation over the long term.
Expanding access to large populations of patients with chronic pulmonary diseases presently
without access to pulmonary rehabilitation programs.
Policy updates:
In 2014, Select Health of South Carolina identified three additional systematic reviews, which would not
materially change the initial findings (Liu, 2014; Beauchamp, 2013; Cavalheri, 2013).
In 2015, Select Health of South Carolina added three new systematic reviews (McCarthy, 2015;
Dowman, 2014; Crandall, 2014) and two guidelines (AHRQ, 2014; Raghu, 2011) to this policy. No
economic analyses were found. Indications covered in the systematic reviews were chronic obstructive
pulmonary disease (McCarthy, 2015), interstitial lung disease (Dowman, 2014), and non-small cell lung
cancer in candidates for lung resection (Crandall, 2014).
In 2016, Select Health of South Carolina found one new systematic review of pulmonary rehabilitation in
persons with mild chronic obstructive pulmonary disease based on Medical Research Council dyspnea
scale (mMRC) levels less than 2 (Rugbjerg, 2015). Moderate-quality evidence suggested a small,
significant improvement in short-term health-related quality of life and a clinically non-significant
improvement in walking distance following pulmonary rehabilitation in patients with chronic obstructive
pulmonary disease and mild symptoms. This resulted in a weak recommendation of routine pulmonary
rehabilitation in these patients.
In 2017, we identified four new systematic reviews and meta-analyses and no new economic studies or
evidence-based guidelines for this policy. The systematic reviews and meta-analyses examined the
effects of pulmonary rehabilitation in persons with chronic obstructive pulmonary disease after
exacerbation (Moore, 2016; Puhan, 2016), in home- or community-based settings (Neves, 2016), and in
persons with non-cystic bronchiectasis (Lee, 2016). The results from randomized controlled trials (RCTs)
and higher quality cohort studies support earlier findings that pulmonary rehabilitation provides short-
term improvement in exercise capacity, health-related quality of life, and, possibly, readmission rates in
persons with stable chronic lung disease, but these improvements are not always maintained over a
longer duration.
Most pulmonary rehabilitation programs are offered in an outpatient setting to patients with stable
chronic lung disease. Limited findings suggest that the short-term effects of pulmonary rehabilitation on
functional capacity and health-related quality of life offered in either home-, community-, or outpatient-
based settings are comparable. However, less is known about cost effectiveness or the optimal patient
selection criteria and program components for home- or community-based settings. These results would
not change earlier findings. Therefore, no changes to the policy are warranted.
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In 2018, we added an update of a previously included systematic review (Lee, 2016, updated 2017) and
a joint guideline on prevention of acute exacerbation of chronic obstructive pulmonary disease by the
ACCP and Canadian Thoracic Society (Criner, 2015). There were no changes to the systematic review
findings. The guideline recommends pulmonary rehabilitation to prevent acute exacerbations in patients
with moderate, severe, or very severe chronic obstructive pulmonary disease who have had a recent
exacerbation within the previous four weeks, based on sufficient evidence that pulmonary rehabilitation
can reduce the risk of hospitalization in this population; there was insufficient evidence to recommend
pulmonary rehabilitation if the acute exacerbation occurred more than four weeks prior. This time
limitation was added to the Limitations section in the policy.
Summary of clinical evidence:
Citation Content, Methods, Recommendations
Lee (2017)
Pulmonary
rehabilitation in
individuals with non-
cystic fibrosis
bronchiectasis
Key points:
Systematic review of four RCTs (164 total participants) comparing pulmonary
rehabilitation (exercise and education) or exercise training to no treatment.
Overall quality: variable risk of bias.
There were significant short-term improvements in exercise capacity and health-related
quality of life with pulmonary rehabilitation or exercise training programs, which were not
always sustained.
The frequency of exacerbations over 12 months was reduced with exercise training only.
Moore (2016)
Pulmonary
rehabilitation as a
mechanism to
reduce
hospitalizations for
acute exacerbations
of chronic
obstructive
pulmonary disease
Key points:
Systematic review and meta-analysis of 10 RCTs (range 16 and 177 participants), three
cohort studies (range 51 and 1,672 participants), and five before-after studies (numbers
not reported).
Overall quality: variable with unclear or high risk of bias.
Results from RCTs, but not from cohort studies, suggest that pulmonary rehabilitation
reduces subsequent admissions for persons with acute exacerbation of chronic
obstructive pulmonary disease in the short term.
This is likely due to the heterogeneous nature of individuals included in observational
research and varying program standards.
Puhan (2016)
Cochrane review
Pulmonary
rehabilitation
following
exacerbations of
chronic obstructive
pulmonary disease
Key points:
Systematic review update included a total of 20 RCTs (1,477 total participants) comparing
pulmonary rehabilitation to usual care.
Overall quality: variable risk of bias and substantial heterogeneity among study designs.
High-quality evidence shows moderate to large effects of pulmonary rehabilitation on
health-related quality of life and exercise capacity.
Some recent studies showed no benefit of pulmonary rehabilitation on hospital
readmissions and mortality, but results may depend on the extensiveness of these
programs and study quality.
Future research should investigate the impact of exercise sessions, self-management
education, and other components on outcomes, and how the organization of such
programs within specific health care systems determines their effects on hospital
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Citation Content, Methods, Recommendations
readmissions and mortality.
Neves (2016)
Effects of home- or
community-based
pulmonary
rehabilitation for
individuals with
chronic obstructive
pulmonary disease
Key points:
Systematic review and meta-analysis of 23 RCTs comparing home-based pulmonary
rehabilitation to controls or community-based pulmonary rehabilitation.
Overall quality: moderate. Limited by insufficient power, short follow-up, and
methodological rigor.
Findings suggest home-based programs were superior to controls based on functional
capacity and dyspnea and health-related quality of life scores and were comparable to
community-based programs based on functional capacity or health-related quality of life .
Improvement was greater in patients with lower FEV1.
Feasibility studies are still needed to implement these programs, including their suitability
in relation to different clinical needs and local contexts. Studies of cost effectiveness of
home-based pulmonary rehabilitation and basic program requirements are needed.
McCarthy (2015)
Cochrane review
Effectiveness of
pulmonary
rehabilitation in
chronic obstructive
pulmonary disease
with mild symptoms
Key points:
Systematic review and meta-analysis of 65 RCTs (3,822 participants).
Overall quality: Lack of blinding not possible, therefore high risk of performance bias; low
or unclear risk of bias in other domains with insufficient detail reported regarding
allocation concealment; high attrition rates.
Most programs were hospital-based (inpatient or outpatient); duration averaged eight to
12 weeks, range four to 52 weeks.
Statistically and clinically significant improvement for all included outcomes of pulmonary
rehabilitation versus usual care, including improvement in dyspnea and fatigue, emotional
function, and sense of control that individuals have over their condition.
Significant difference in treatment effect on St. George’s Respiratory Questionnaire
scores between hospital-based and community-based programs, but no difference
between exercise-only and more complex pulmonary rehabilitation programs.
Future research studies should focus on identifying which components of pulmonary
rehabilitation are essential, its ideal length and location, the degree of supervision and
intensity of training required, and how long treatment effects persist.
Rugbjerg (2015)
Chronic obstructive
pulmonary disease
with mild symptoms
Key points:
Systematic review of four RCTs (489 participants).
Overall quality: moderate.
Effects of pulmonary rehabilitation:
- Clinically and statistically significant improvement in short-term health-related
quality of life of 4.2 units (95% confidence interval [CI] -4.51 to -3.89) on St
George's Respiratory Questionnaire, but not at the longest follow-up.
- Small, statistically significant improvement of 25.71 meters (95% CI 15.76 to 35.65)
in the six-minute walk test, but not clinically relevant.
No difference was found for mortality, and insufficient data prohibited meta-analysis for
muscle strength and maximal exercise capacity. No adverse effects reported.
Crandall (2014)
Exercise
intervention for
Key points:
Systematic review of 20 studies (eight RCTs, 12 observational) of pulmonary
rehabilitation pre- and/or post-lung cancer resection.
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Citation Content, Methods, Recommendations
patients surgically
treated for non-small
cell lung cancer
Overall quality: low due to small samples; inadequate allocation concealment;
heterogeneous programs and outcomes; and a lack of clear reporting on timing, adverse
events, and follow-up.
Exercise intervention compared with usual care both pre- and post-surgery improved
cardiopulmonary exercise capacity; increased muscle strength; and reduced fatigue, post-
operative complications, and hospital length of stay. Effects on pulmonary function,
quality of life and blood gas analysis were variable and inconsistent.
Patients who had impaired exercise capacity at baseline (maximum O2 uptake [VO2 max]
< 15 ml/kg/mi) benefited most from exercise intervention.
RCTs of feasibility, acceptability, and effectiveness of specific interventions on outcomes
are warranted.
Dowman (2014)
Cochrane review
Pulmonary
rehabilitation for
interstitial lung
disease
Key points:
Systematic review of nine RCT or quasi-RCT comparative studies of pulmonary
rehabilitation versus other or no therapy.
Overall quality: low to moderate due to inadequate reporting and small studies.
Pulmonary rehabilitation appears to be safe for people with interstitial lung disease. Short-
term improvements in functional exercise capacity, dyspnea, and quality of life, with
benefits also evident in persons with interstitial pulmonary fibrosis.
Insufficient evidence to examine the impact of disease severity or exercise training
modality or on longer-term effects.
Liu (2014)
Effectiveness of
home-based
pulmonary
rehabilitation for
patients with chronic
obstructive
pulmonary disease
Key points:
Meta-analysis of 18 RCTs (n = 733) of patients with chronic obstructive pulmonary
disease who underwent 12 weeks of home-based pulmonary rehabilitation versus no
intervention.
Quality assessment: low to unclear risk of bias.
Statistically significant improvement in dyspnea status, health-related quality of life
scores, exercise capacity, and pulmonary function (measured by FEV1/FVC).
No statistically significant changes in maximal workload, hospital admission, cost of care,
or mortality between the two groups.
Rigorously designed, large-scale RCTs are still needed to identify an optimal standard
home-based pulmonary rehabilitation program.
Beauchamp (2013)
Supervised exercise
programs after
pulmonary
rehabilitation in
individuals with
chronic obstructive
pulmonary disease
Key points:
Systematic review of seven RCTs (619 participants) with moderate-to-severe chronic
obstructive pulmonary disease.
At six-month follow-up there was a significant difference in exercise capacity in favor of
the post-rehabilitation interventions (standardized mean difference [SMD] -0.20; 95% CI, -
0.39 to -0.01), not sustained at 12 months (SMD, -0.09; 95% CI, -0.29 to 0.11).
No effect on health-related quality of life.
Cavalheri (2013)
Cochrane review
Exercise training
Key points:
Systematic review of three RCTs (178 participants) post-lung resection,with or without
chemotherapy.
Quality of evidence: low with high risk of bias.
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Citation Content, Methods, Recommendations
undertaken by
people within 12
months of lung
resection for non-
small cell lung
cancer
Exercise training was effective in increasing exercise capacity vs. control group (mean
difference [MD] 50.4 m; 95% confidence interval [CI] 15.4 m to 85.2 m).
No between-group differences in health-related quality of life (SMD 0.17; 95% CI -0.16 to
0.49) or FEV1 (MD-0.13 L; 95% CI -0.36 to 0.11 L).
No differences in quadriceps force.
Larger RCTs needed.
References
Professional society guidelines/other:
Bolton CE, Bevan-Smith EF, Blakey JD, et al. British Thoracic Society guideline on pulmonary
rehabilitation in adults. Thorax. 2013; 68(Suppl 2): ii1 – 30. DOI: 10.1136/thoraxjnl-2013-203808.
Criner GJ, Bourbeau J, Diekemper RL, et al. Executive Summary. Chest. 2015; 147(4): 883 – 893. DOI:
10.1378/chest.14-1677.
Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary
Disease (2018 report). Global Initiative for Chronic Obstructive Lung Disease website.
http://goldcopd.org/wp-content/uploads/2017/11/GOLD-2018-v6.0-FINAL-revised-20-Nov_WMS.pdf .
Accessed January 19, 2018.
Lung Health & Diseases. How Serious Is COPD? Last reviewed December 18, 2017. American Lung
Association website. http://www.lung.org/lung-health-and-diseases/lung-disease-lookup/copd/learn-
about-copd/how-serious-is-copd.html . Accessed January 19, 2018.
Qaseem A, Wilt TJ, Weinberger SE, et al. 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. DOI: 10.7326/0003-4819-155-3-201108020-00008.
Ries A, Bauldoff G, Carlin B, et al. Pulmonary Rehabilitation*Joint ACCP/AACVPR Evidence-Based Clinical
Practice Guidelines. CHEST. May 2007; 131: 4S – 42S. DOI: 10.1378/chest.06-2418.
Spruit MA, Singh SJ, Garvey C, et al. An official American Thoracic Society/European Respiratory Society
statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med. 2013 Oct
15; 188(8): e13 – 64. DOI: 10.1164/rccm.201309-1634ST.
Peer-reviewed references:
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Beauchamp MK, Evans R, Janaudis-Ferreira T, Goldstein RS, Brooks D. Systematic review of supervised
exercise programs after pulmonary rehabilitation in individuals with chronic obstructive pulmonary
disease. Chest. 2013 Oct; 144(4): 1124 – 1133. DOI: 10.1378/chest.12-2421.
Cavalheri V, Tahirah F, Nonoyama M, Jenkins S, Hill K. Exercise training undertaken by people within 12
months of lung resection for non-small cell lung cancer. Cochrane Database Syst Rev. 2013; 7:
Cd009955. DOI: 10.1002/14651858.CD009955.pub2.
Crandall K, Maguire R, Campbell A, Kearney N. Exercise intervention for patients surgically treated for
Non-Small Cell Lung Cancer (NSCLC): a systematic review. Surg Oncol. 2014; 23(1): 17 – 30. DOI:
10.1016/j.suronc.2014.01.001.
Dowman L, Hill CJ, Holland AE. Pulmonary rehabilitation for interstitial lung disease. Cochrane Database
Syst Rev. 2014; 10: CD006322. DOI: 10.1002/14651858.CD006322.pub3.
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.e771. DOI:
10.1016/j.apmr.2016.05.017.
Liu XL, Tan JY, Wang T, et al. Effectiveness of home-based pulmonary rehabilitation for patients with
chronic obstructive pulmonary disease: a meta-analysis of randomized controlled trials. Rehabil Nurs.
2014 Jan – Feb; 39(1): 36 – 59. DOI: 10.1002/rnj.112.
McCarthy B, Casey D, Devane D, Murphy K, Murphy E, Lacasse Y. Pulmonary rehabilitation for chronic
obstructive pulmonary disease. Cochrane Database Syst Rev. 2015; 2: CD003793. DOI:
10.1002/14651858.CD003793.pub3.
Moore E, Palmer T, Newson R, et al. Pulmonary Rehabilitation as a Mechanism to Reduce
Hospitalizations for Acute Exacerbations of COPD: A Systematic Review and Meta-Analysis. Chest. 2016;
150(4): 837 – 859. DOI: 10.1016/j.chest.2016.05.038.
Neves LF, Reis MH, Goncalves TR. Home or community-based pulmonary rehabilitation for individuals
with chronic obstructive pulmonary disease: a systematic review and meta-analysis. Cad Saude Publica.
2016; 32(6). DOI: 10.1590/0102-311x00085915.
Puhan MA, Gimeno-Santos E, Cates CJ, Troosters T. Pulmonary rehabilitation following exacerbations of
chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2016; 12: Cd005305. DOI:
10.1002/14651858.CD005305.pub4.
Rugbjerg M, Iepsen UW, Jorgensen KJ, Lange P. Effectiveness of pulmonary rehabilitation in chronic
obstructive pulmonary disease with mild symptoms: a systematic review with meta-analyses. Int J Chron
Obstruct Pulmon Dis. 2015; 10: 791 – 801. DOI: 10.2147/copd.s78607.
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CMS National Coverage Determinations (NCDs):
National Coverage Determination (NCD) for Pulmonary Rehabilitation Services (240.8). CMS website.
http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=320&ver=1.
Accessed January 19, 2018.
A52696 Educational Article - Pulmonary Rehabilitation (PR) Services. CMS website.
http://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52696&ver=3.
Accessed January 19, 2018.
A52756 Pulmonary Rehabilitation Services. CMS website. http://www.cms.gov/medicare-coverage-
database/details/article-details.aspx?articleId=52756&ver=2 . Accessed January 19, 2018.
A52770 Pulmonary Rehabilitation Services. CMS website. http://www.cms.gov/medicare-coverage-
database/details/article-details.aspx?articleId=52770&ver=2. Accessed January 19, 2018.
Local Coverage Determinations (LCDs):
No LCDs identified as of the writing of this policy.
Commonly submitted codes
Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is
not an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and
bill accordingly.
CPT Code Description Comments
N/A
ICD-10 Code Description Comments
D86.0 Sarcoidosis of lung
D86.2 Sarcoidosis of lung with sarcoidosis of lymph nodes
D86.82 Multiple cranial nerve palsies in sarcoidosis
D86.85 Sarcoid myocarditis
E84.0 Cystic fibrosis with pulmonary manifestations
E84.8 Cystic fibrosis with other manifestations
G12.21 Amyotrophic lateral sclerosis
G61.0 Guillain-Barre syndrome
J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection
J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation
J44.9 Chronic obstructive pulmonary disease, unspecified
J44.9 Chronic obstructive pulmonary disease, unspecified
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ICD-10 Code Description Comments
J45.20 Mild intermittent asthma, uncomplicated
J45.20 Mild intermittent asthma, uncomplicated
J45.21 Mild intermittent asthma with (acute) exacerbation
J45.22 Mild intermittent asthma with status asthmaticus
J45.30 Mild persistent asthma, uncomplicated
J45.30 Mild persistent asthma, uncomplicated
J45.31 Mild persistent asthma with (acute) exacerbation
J45.32 Mild persistent asthma with status asthmaticus
J45.40 Moderate persistent asthma, uncomplicated
J45.41 Moderate persistent asthma with (acute) exacerbation
J45.42 Moderate persistent asthma with status asthmaticus
J45.50 Severe persistent asthma, uncomplicated
J45.51 Severe persistent asthma with (acute) exacerbation
J45.52 Severe persistent asthma with status asthmaticus
J45.901 Unspecified asthma with (acute) exacerbation
J45.902 Unspecified asthma with status asthmaticus
J45.909 Unspecified asthma, uncomplicated
J45.990 Exercise induced bronchospasm
J45.991 Cough variant asthma
J45.998 Other asthma
J47.0 Bronchiectasis with acute lower respiratory infection
J47.1 Bronchiectasis with (acute) exacerbation
J47.9 Bronchiectasis, uncomplicated
J84.112 Idiopathic pulmonary fibrosis
Z48.24 Encounter for aftercare following lung transplant
Z48.280 Encounter for aftercare following heart-lung transplant
Z94.2 Lung transplant status
Z94.3 Heart and lungs transplant status
HCPCS
Level II Code Description Comments
G0302
Preoperative pulmonary surgery services for preparation for lung volume reduction
surgery (LVRS), complete course of services, to include a minimum of 16 days of
services
G0303 Preoperative pulmonary surgery services for preparation for LVRS, 10 to 15 days of
services
G0304 Preoperative pulmonary surgery services for preparation for LVRS, 1 to 9 days of
services
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
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