NCD 240.8

Item/Service Description

A. General

Pulmonary rehabilitation was defined in a 1999 joint statement of the American Thoracic Society and the European Respiratory Society as a multi-disciplinary program of care for patients with chronic respiratory impairment that is individually tailored and designed to optimize physical and social performance and autonomy and an evidence-based, multidisciplinary, and comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activities. Integrated into the individualized treatment of the patient, pulmonary rehabilitation is designed to reduce symptoms, optimize functional status, increase participation, and reduce health care costs through stabilizing or reversing systematic manifestations of the disease.

Although services that make up pulmonary rehabilitation individually may be covered under Medicare and fall into various applicable benefit categories, the Centers for Medicare & Medicaid Services (CMS) has determined that the Social Security Act (the Act) does not expressly define a comprehensive Pulmonary Rehabilitation Program as a Part B benefit. In addition, respiratory therapy services are identified as covered services under the Comprehensive Outpatient Rehabilitation Facility benefit and defined in 42 CFR 410.100(e)(1) to (2)(vi).

Indications and Limitations of Coverage

B. Nationally Covered Indications

N/A

C. Nationally Non-Covered Indications

N/A

D. Other

The CMS has determined that a national coverage determination (NCD) for pulmonary rehabilitation is not appropriate at this time. Local Medicare Administrative Contractors should continue to make decisions under §1862(a)(1)(A) of the Act through their local coverage determination (LCD) process or by case-by-case adjudication. See Heckler v. Ringer, 466 U.S. 602, 617 (1984) (Recognizing that the Secretary has discretion to either establish a generally applicable rule or to allow individual adjudication.). See also, 68 Fed. Reg. 63692, 63693 (November 7, 2003). LCDs can be accessed from the CMS search engine located at: http://www.cms.gov/mcd/search.asp.

(This NCD last reviewed September 2007.)

Revision History

12/2007 - Provided noncoverage policy. Effective date 09/25/2007. (TN 78) (CR5834)