Page 235 - Medicare Benefit Policy Manual

program that furnishes CR and has shown, in peer-reviewed published research, that it
improves patients’ cardiovascular disease through specific outcome measurements
described in 42 CFR 410.49(c). Effective January 1, 2010, Medicare Part B pays for
CR/ICR if specific criteria are met by the Medicare beneficiary, the CR/ICR program
itself, the setting in which it is administered, and the physician administering the
program, as outlined below.

Covered Conditions:

As specified in 42 CFR 410.49, Medicare Part B covers CR and ICR for beneficiaries
who have experienced one or more of the following:

• An acute myocardial infarction (MI) within the preceding 12 months;
• A coronary artery bypass surgery;
• Current stable angina pectoris;
• Heart valve repair or replacement;
• Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting;
• A heart or heart-lung transplant.
• 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, on
or after February 18, 2014 for CR and on or after February 9, 2018 for ICR; or,
• Other cardiac conditions as specified through a national coverage determination
(NCD). The NCD process may also be used to specify non-coverage of a
cardiac condition for ICR if coverage is not supported by clinical evidence.

CR and ICR must include all of the following components:

Physician-prescribed exercise. Physician-prescribed exercise means aerobic exercise
combined with other types of exercise (such as strengthening and stretching) as
determined to be appropriate for individual patients by a physician each day CR/ICR
items and services are furnished.

Cardiac risk factor modification. Cardiac risk factor modification, including education,
counseling, and behavioral intervention, tailored to the individual’s needs.

Psychosocial assessment. Psychosocial assessment means an evaluation of an
individual’s mental and emotional functioning as it relates to the individual’s
rehabilitation which includes an assessment of those aspects of an individual’s family and
home situation that affects the individual’s rehabilitation treatment, and psychosocial
evaluation of the individual’s response to and rate of progress under the treatment plan.

Outcomes assessment. Outcomes assessment means an evaluation of progress as it relates
to the individual’s rehabilitation which includes all of the following: (i) Evaluations,
based on patient-centered outcomes, which must be measured by the physician or
program staff at the beginning and end of the program. Evaluations measured by program