NCD 20.10.1

Item/Service Description

A. General

As per sections 1861(s)(2)(CC) and 1861(eee)(1) of the Social Security Act, items and services furnished under a Cardiac Rehabilitation (CR) program may be covered under Medicare Part B. Among other things, Medicare regulations at 42CFR410.49 define key terms, address the components of a CR program, establish the standards for physician supervision, and limit the maximum number of program sessions that may be furnished. The regulations also describe the cardiac conditions that would enable a beneficiary to obtain CR services.

Effective for dates of service on and after January 1, 2010, coverage is permitted for beneficiaries who have experienced one or more of the following:

• Acute myocardial infarction within the preceding 12 months

• Coronary artery bypasses surgery

• Current stable angina pectoris

• Heart valve repair or replacement

• Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting

• A heart or heart-lung transplant

The Centers for Medicare & Medicaid Services (CMS) may add “other cardiac conditions as specified through a national coverage determination” (See 42 CFR §410.49(b)(1)(vii)).

Indications and Limitations of Coverage

B. Nationally Covered Indications

Effective for dates of service on and after February 18, 2014, CMS has determined that the evidence is sufficient to expand coverage for cardiac rehabilitation services under 42 CFR §410.49(b)(1)(vii) 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 six weeks. Stable patients are defined as patients who have not had recent (≤ 6 weeks) or planned (≤ 6 months) major cardiovascular hospitalizations or procedures. (See section A above for other indications covered under 42 CFR §410.49(b)(1)(vii)).

C. Nationally Non-Covered Indications

Any cardiac indication not specifically identified in 42 CFR §410.49(b)(1)(vii) or identified as covered in this NCD or any other NCD in relation to cardiac rehabilitation services is considered non-covered.

D. Other

NA

(This NCD last reviewed February 2014.)

Revision History

07/2014 - The purpose of this Change Request (CR) is effective for dates of service on and after February 18, 2014, Medicare covers 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. Effect date: 02/18/2014. Implementation date: 08/18/2014. (TN 171) (CR8758)