Outpatient Pulmonary Rehabilitation
DESCRIPTION
Pulmonary rehabilitation is defined as a multidisciplinary approach to the rehabilitation of individuals who are diagnosed with a chronic pulmonary disease. Pulmonary rehabilitation programs include exercise training, psychosocial support, education, and follow up in an outpatient facility. All of these components are intended to improve the individuals functioning and quality of life. Individuals must be medically stable and without limitations by another medical/psychological problem.
POLICY
Outpatient pulmonary rehabilitation for the treatment of a documented diagnosis of moderate to severe chronic obstructive pulmonary disease (COPD), either emphysema or chronic bronchitis, is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Outpatient pulmonary rehabilitation as a preoperative conditioning component for individuals that are candidates for lung volume reduction surgery and lung transplantation is considered medically necessary. (NOTE: As related to this policy, outpatient pulmonary rehabilitation visits may be limited per individual contract benefits.)
Outpatient pulmonary rehabilitation for the treatment of other conditions, including but not limited to, asthma, cystic fibrosis, bronchopneumonia, dysplasia or simple shortness of breath is considered investigational.
Home-based pulmonary rehabilitation programs are considered investigational.
MEDICAL APPROPRIATENESS
Outpatient pulmonary rehabilitation for the treatment of a documented diagnosis of moderate to severe chronic obstructive pulmonary disease (COPD), either emphysema or chronic bronchitis, is considered medically appropriate when ALL of the following exists:
Documentation of ALL of the following:
Activities of daily living (ADL) are currently limited by breathing difficulty
Moderate to severe lung function impairment by pulmonary function tests: FEV1 at values 25-60% of prediction (Note: Values below 25% indicate severe disease process; levels over 60% denote normalization)
No other medical/psychological limitations (e.g., congestive heart failure, substance abuse, significant liver dysfunction, metastatic cancer, disabling stroke, dementia, organic brain syndrome)
Non-smoker more than one month
Stable on medical therapy (e.g., routine care under physician, compliance with medications and other prescribed treatments)
Program addresses ALL of the following components:
Can be accomplished short-term
Team assessment includes input from a physician, respiratory care practitioner, nurse, and psychologist (may include others if applicable), and includes individual goals of treatment
Exercise training that includes strengthening and conditioning such as include stair climbing, inspiratory muscle training, treadmill walking, cycle training with or without ergometer, and possibly upper extremity exercise - note that management without exercise does not improve health outcomes
Individual training involving breathing retraining, bronchial hygiene, medications, and proper nutrition;
Intervention is on an outpatient basis
Psychosocial intervention that addresses support system and dependency issues
Follow-up including understanding of a home-based pulmonary rehabilitation program and a means of tracking progression
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
ADDITIONAL INFORMATION
The data is inadequate to permit scientific conclusions regarding the applications of pulmonary rehabilitation for the treatment of the other conditions including but not limited to the conditions listed as investigational.
There is a lack of published evidence-based, randomized controlled trials and well-designed studies to determine whether the home-based pulmonary rehabilitation programs improve net health outcomes.
SOURCES
Ambrosino, N., Palmiero, G., & Strambi, S. (2007). New approaches in pulmonary rehabilitation. Clinics in Chest Medicine, 28 (3), 629-638.
BlueCross BlueShield Association. Medical Policy Reference Manual. (2:2011). Outpatient pulmonary rehabilitation (8.03.05). Retrieved April 14, 2011 from BlueWeb. (17 articles and/or guidelines reviewed)
Casaburi, R. (2008). A brief history of pulmonary rehabilitation. Respiratory Care, 53 (9), 1185-1189.
Complete Guide to Medicare Coverage Issues [Computer software]. (2011, April). Pulmonary rehabilitation services (NCD 240.8, p. 2-207). Ingenix.
Ghanem, M., Elaal, E. A., Mehany, M., & Tolba, K. (2010). Home-based pulmonary rehabilitation program: Effect on exercise tolerance and quality of life in chronic obstructive pulmonary disease patients. Annals of Thoracic Medicine, 5 (1), 18-25. (Level 3 Evidence - Independent study)
Korczak, D., Huber, B., Steinhauser, G., & Dieti, M. (2010). Outpatient pulmonary rehabilitation - rehabilitation models and shortcomings in outpatient aftercare. GMS Health Technology Assessment, 29 (6).
Koza, R., Senjyu, H., Jenkins, S., Mukae, H., Sakamoto, N., Kohno, S. (2011). Differences in response to pulmonary rehabilitation in idiopathic pulmonary fibrosis and chronic obstructive pulmonary disease. Respiration, 81 (3), 196-205. (Level 3 Evidence - Independent study)
Lacasse, Y., Martin, S., Lasserson, T. J., & Goldstein, R. S. (2007). Meta-analysis of respiratory rehabilitation in chronic obstructive pulmonary disease. A Cochrane systematic review. Europa Medicophysica, 43 (4), 475-485.
Maltais, F., Bourbeau, J., Shapiro, S., Lacasse, Y., Perrault, H., Baltzan, M., et al. (2008). Effects of home-based pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: A randomized trial. Annals of Internal Medicine, 149 (12), 869-878. (Level 1 Evidence - Independent study)
Qaseem, A., Snow, V., Shekelle, P., Sherif, K., Wilt, T. J., Weinberger, S., et al. (2007). Diagnosis and management of stable chronic obstructive pulmonary disease: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 147 (9), 633-638.
Ries, A. L. (2008). Pulmonary rehabilitation: Summary of an evidence-based guideline. Respiratory Care, 53 (9), 1203-1207.
Ries, A. L., Bauldoff, G. S., Carlin, B. W., Casaburi, R., Emery, C. F., Mahler, D. A., et al. (2007). Pulmonary rehabilitation: Joint ACCP/AACVPR evidence-based clinical practice guidelines. Chest, 131 (5), 4-42.
Rochester, C. L. (2008, September). Pulmonary rehabilitation for patients who undergo lung-volume-reduction surgery or lung transplantation. Respiratory Care, 53 (9), 1196-1202.
Salhi, B., Troosters, T., Behaegel, M., Joos, G., & Derom, E. (2010). Effects of pulmonary rehabilitation in patients with restrictive lung diseases. Chest, 137 (2), 273-279. (Level 3 Evidence - Independent study)
Smith, L. (2008). ACCP and AACVPR release evidence-based guidelines on pulmonary rehabilitation. American Family Physician, 77 (2), 242-244.
ZuWallack, R., & Hedges, H. (2008). Primary care of the patient with chronic obstructive pulmonary disease - Part 3: Pulmonary rehabilitation and comprehensive care for the patient with chronic obstructive pulmonary disease. The American Journal of Medicine, 121 (7 Suppl.), S25-S32.
ORIGINAL EFFECTIVE DATE: 6/1999
MOST RECENT REVIEW DATE: 9/11/2011
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Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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