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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