S0342 — Lifestyle modification program for management of coronary artery disease, including all supportive services; fourth quarter / stage
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- When billing G0422 or G0423, selection criteria must be met and documented (HCPCS codes covered if selection criteria are met).
- Member must meet medical necessity criteria for cardiac rehabilitation as outlined in CPB 0021 - Cardiac Rehabilitation: Outpatient (i.e., documentation that patient meets CPB 0021 criteria is required).
- Documentation of qualifying cardiac diagnosis consistent with CMS §1861(eee)(4)(B) (e.g., acute myocardial infarction within preceding 12 months; coronary bypass surgery; stable angina pectoris; heart valve repair/replacement; PTCA or coronary stenting; heart or heart-lung transplant).
- Program-level documentation (required for program approval/coverage): peer-reviewed published research demonstrating that the program (a) positively affected progression of coronary heart disease and/or reduced need for coronary bypass surgery or percutaneous coronary interventions; and (b) accomplished a statistically significant reduction in five or more of the specific measures (LDL, triglycerides, BMI, systolic BP, diastolic BP, and need for cholesterol/BP/diabetes medications) from before to after cardiac rehabilitation services.
Key Coverage Criteria
- had percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting;
- had a heart or heart-lung transplant.
- ICD-10 codes listed in the policy as 'covered if selection criteria are met' (i.e., covered diagnoses when selection criteria are satisfied): I02.0; I05.0 - I08.9; I09.81; I11.0; I13.0; I13.2; I21.01 - I25.9; I21.A1; I21.A9; I34.0 - I37.9; I42.3 - I42.7; I46.2 - I46.9; I47.20 - I47.29; I47.9; I49.01 - I49.02; I50.1 - I50.9; I97.0; I97.110; I97.130; I97.190; Z51.89; Z94.1; Z94.2; Z95.1; Z95.2; Z95.3; Z95.4; Z95.811; Z95.812; Z98.61; Z98.890 - Z98.891.
- Aetna considers intensive cardiac rehabilitation (ICR) programs (i.e. Benson-Henry Institute Cardiac Wellness Program, Ornish cardiac treatment program, and Pritikin Program) a medically necessary alternative to traditional Phase II cardiac rehabilitation for persons who meet medical necessity criteria for cardiac rehabilitation as outlined in CPB 0021 - Cardiac Rehabilitation: Outpatient.
- As required by CMS §1861(eee)(4)(B) of the Act, to be eligible for an intensive cardiac rehabilitation program, an individual must have (CMS, 2014): had an acute myocardial infarction within the preceding 12 months; had coronary bypass surgery; stable angina pectoris; had heart valve repair or replacement; had percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting; or had a heart or heart-lung transplant.
- HCPCS codes covered if selection criteria are met: G0422 Intensive cardiac rehabilitation; with or without continuous ECG monitoring with exercise, per session; G0423 Intensive cardiac rehabilitation; with or without continuous ECG monitoring; without exercise, per session.
1 Active Policy
AETNA-CPB-0267 — Intensive Cardiac Rehabilitation Programs
Related Codes
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