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MP 8.03.05 Outpatient Pulmonary Rehabilitation

Medical Policy    
Section
Therapy
 
Original Policy Date
7/31/96
Last Review Status/Date
Local policy reviewed with literature search/1:2013
Issue
1:2013
  Return to Medical Policy Index

Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically. 


Description

Pulmonary rehabilitation is a multidisciplinary approach to reducing symptoms and improving quality of life in patients with compromised lung function. The approach can be used in patients with chronic pulmonary disease and as preoperative conditioning before lung surgery.

The American Thoracic Society (ATS) and the European Respiratory Society (ERS) define pulmonary rehabilitation (PR) as “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 systemic manifestations of the disease. Comprehensive pulmonary rehabilitation programs include patient assessment, exercise training, and psychosocial support.” (1)

Pulmonary rehabilitation programs are intended to improve the patient’s functioning and quality of life. The vast majority of study has focused on patients with chronic obstructive pulmonary disease (COPD), although there has been some interest in pulmonary rehabilitation in patients with asthma, cystic fibrosis, or bronchiectasis. According to a joint ATS/ERS statement issued in 2006, pulmonary rehabilitation may be of value for conditions other than COPD in cases where respiratory symptoms are associated with diminished functional capacity or reduced health-related quality of life.

Pulmonary rehabilitation is also routinely offered to patients awaiting lung transplantation and lung volume reduction surgery (LVRS). PR before lung surgery may stabilize or improve patients’ exercise tolerance, teach patients techniques that will help them recover after the procedure and allow health care providers to identify individuals who might be suboptimal surgical candidates due to non-compliance, poor health or other reasons.

Regulatory Status
Not applicable


Policy

A single course of pulmonary rehabilitation in the outpatient ambulatory care setting may be considered medically necessary for outpatient treatment of chronic pulmonary disease for patients with moderate-to severe disease (GOLD guidelines)  who are experiencing disabling symptoms and significantly diminished quality of life in spite of optimal medical management.

A single course of pulmonary rehabilitation may be considered medically necessary in an outpatient ambulatory care setting as a preoperative conditioning component for those considered appropriate candidates for lung volume reduction surgery (see policy No. 7.01.71) and for lung transplantation (see policy No. 7.03.07).

Multiple courses of pulmonary rehabilitation are considered investigational, either as maintenance therapy in patients who initially respond or in patients who fail to respond or whose response to an initial rehabilitation program has diminished over time.

Home-based pulmonary rehabilitation programs are considered investigational.


Policy Guidelines

Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines to determine severity of disease are as follows:

Mild - FEV1 ≥ 80% predicted
Moderate - 50% ≤ FEV1, <80% predicted
Severe - 30% ≤FEV1, <50% predicted
Very Severe - FEV1 <30% predicted

A pulmonary rehabilitation outpatient program generally includes team assessment, patient training, psychosocial intervention, exercise training, and follow-up. The overall length of the program and the total number of visits for each component may vary from program to program.

Team assessment includes input from a physician, respiratory care practitioner, nurse, and psychologist, among others.

Patient training includes breathing retraining, bronchial hygiene, medications, and proper nutrition.

Psychosocial intervention addresses support system and dependency issues.

Exercise training includes strengthening and conditioning and may include stair climbing, inspiratory muscle training, treadmill walking, cycle training (with or without ergometer), and supported and unsupported arm exercise training. Exercise conditioning is an essential component of pulmonary rehabilitation. Education in disease management techniques without exercise conditioning does not improve health outcomes of patients who have chronic obstructive pulmonary disease.

Follow-up includes a structured home pulmonary rehabilitation program and may include supervised home exercise conditioning.

Candidates for pulmonary rehabilitation should be medically stable and not limited by another serious or unstable medical condition. Contraindications to pulmonary rehabilitation include severe psychiatric disturbance (e.g., dementia, organic brain syndrome), and significant or unstable medical conditions (e.g., congestive heart failure, acute cor pulmonale, substance abuse, significant liver dysfunction, metastatic cancer, disabling stroke).

While there are global HCPCS codes for pulmonary rehabilitation services such as G0237-G2039, G0302-G0305, G0424 and S9473, the component services may be reported separately using CPT codes such as 97110 and 97530, or an unlisted code such as 94799 or 97799 may be reported.


Benefit Application
BlueCard/National Account Issues

In general, a global fee is submitted for pulmonary rehabilitation that includes all components of the program. If billing is per session, recommendation is made to adjudicate sessions as a 1 program per lifetime benefit. Programs usually last 6–8 weeks in duration. Another alternative for a program not billed as a global fee is to add a dollar or visit maximum.


Rationale

The original policy issued in July 1996 was based on a TEC Assessment. (2) The policy was updated regularly with searches of the MEDLINE database. The most recent literature search was performed for the period December 2011 through November 2012. Following is a summary of the literature to date.

Initial course of pulmonary rehabilitation programs for patients with chronic pulmonary disease

Patients with Chronic Obstructive Pulmonary Disease (COPD)

There are 2 Cochrane Collaboration systematic reviews of randomized controlled trials (RCTs) on pulmonary rehabilitation (PR) for COPD. Both reviews included inpatient, outpatient, and in-home patients and did not stratify their findings by location of program. Lacasse and colleagues reviewed the literature through July 2005 and identified RCTs comparing rehabilitation programs of at least 4 weeks’ duration to usual care for patients with a clinical diagnosis of COPD. (3) The primary outcomes were health-related quality of life (HRQOL) and/or maximal or functional exercise capacity in 4 important domains of quality of life (QOL: dyspnea, fatigue, emotional function, and mastery). The effect of PR was greater than the minimal clinically important difference of 0.5 units. Moreover, there was statistically significant greater improvement in the PR group for 2 of the 3 domains in the St. George’s Respiratory Questionnaire (SGRQ). The other Cochrane review, by Puhan and colleagues, searched the literature through March 2010 and included studies on the effect of outpatient or inpatient PR following an acute exacerbation of COPD. (4) To be included, the rehabilitation program needed to begin within 3 weeks of initiating exacerbation treatment and had to include physical exercise. Nine trials with a total of 432 participants met inclusion criteria. Rehabilitation was outpatient in 4 trials, inpatient in 4 trials, and the fifth trial included both in- and out-patient rehabilitation. In a pooled analysis of 5 trials, there was a statistically significant reduction in the primary outcome, rate of hospital admissions, with PR compared to usual care (odds ratio [OR]: 0.22, 95% confidence interval [CI]: 0.08 to 0.58). Secondary outcomes also favored the PR group. For example, there was also a significant reduction in mortality with PR when findings from 3 studies were pooled (OR: 0.28, 95% CI: 0.10 to 0.84). In addition, in a pooled analysis of 6 studies, there was a greater change from baseline in the 6 minute walk distance (6MWD) with PR (mean difference=77.7 meters, 95% CI: 12.1 to 143.2 meters).

A 2010 systematic review by Vieira and colleagues focused on RCTs of home-based PR for patients with COPD. (5) Eligible trials included patients at least 40-years-old; programs could compare home-based PR to rehabilitation in another setting or to standard care but needed to have a minimum duration of 4 weeks or 12 sessions. Studies evaluating home-based PR for maintaining the effects of inpatient or outpatient rehabilitation were excluded. Twelve studies met the inclusion criteria; the comparison intervention in 3 studies was a hospital-based program, in 8 studies was standard care, and 1 study had both types of comparisons. The methodologic quality of the studies was considered to be average to poor, and most had small sample sizes and relatively short follow-up duration. (The largest trial was by Maltais and colleagues and had 252 participants; it is described in a later section of the Rationale). Only 3 of the 8 studies that compared home-based PR to standard care reported data on between-group differences in QOL; in all 3 studies, differences were reported as statistically significant. The 2 studies that reported differences in exercise capacity found home-based PR to result in significantly greater improvement in the 6-minute walk distance (6MWD) or constant work rate test than standard care. On the other hand, in the 3 studies comparing home-based PR and hospital-based programs, there were no statistically significant differences between groups in quality-of-life changes. Moreover, in the 2 studies that assessed maximal work level and the 2 studies that assessed the 6-minute walk test (6MWT), outcomes did not differ significantly after home-based or hospital-based PR programs. The authors commented that the review was limited by the generally low quality of the randomized trials and that most studies had only short-term follow-up.

In 2011, Beauchamp and colleagues conducted a systematic review of trials on pulmonary rehabilitation for COPD, with the aim of determining the optimal duration of rehabilitation programs. (6) Five studies met inclusion criteria which were that studies needed to be randomized and compare different lengths of rehabilitation and that more than 90% of patients in the study needed to be diagnosed with COPD. A pooled analysis of findings was not possible due to heterogeneity of PR program duration and outcome measures. Three of the trials reported a significant difference in quality of life in favor of the longer programs. The length of programs was 18 month versus 3 months in 2 studies and 7 weeks versus 4 weeks in the third study. In the other 2 trials, there was not a statistically significant difference between groups.

A review of a representative sample of randomized trials is provided below. Of interest, PR programs differed, both in the individual components of the program and its duration. For example, the programs ranged in length from 6 weeks to 6 months. In addition, all the randomized studies were conducted outside the United States, and thus conclusions regarding the structure of a PR program may not be applicable to the U.S. healthcare system.

Guell and colleagues reported on the results of a study that randomly assigned 60 patients with COPD to undergo PR or standard care. (7) The specific focus of the study was to examine the long-term effects (24 months) of the PR program. The patients received breathing retraining in the first 3 months followed by exercise training in the next 3 months. The improvement in both symptoms and QOL noted at 3 months after completion of the program continued with somewhat diminished magnitude in the second year of follow-up.

Griffiths and colleagues focused on the use of health services over 1 year in a group of 200 patients with COPD who were randomly assigned to a PR program or standard medical management. (8) The days spent in the hospital were substantially lower in the PR group compared to the control group. The PR group also showed greater improvement in walking ability and disease-specific health status, which declined with time, similar to the Guell et al. study.

Wedzicha and colleagues examined the effects of a PR program in patients with moderately severe and severe COPD who were randomly assigned to receive an 8-week program of PR or standard care. (9) Patients with severe COPD were treated at home. While significant improvement was noted in exercise performance and QOL among those with moderately severe COPD assigned to the PR program, no improvement was found in those with severe COPD.

Maltais and colleagues conducted a non-inferiority trial in Canada with 252 patients with COPD. (10) Eligibility criteria included stable COPD for at least 4 weeks before study participation and no previous participation in PR programs. All patients initially completed a 4-week self-management educational program. They were then randomized to receive 8 weeks of either self-monitored home-based exercise training or outpatient hospital-based exercise training. The exercise program included aerobic and strength exercises conducted 3 times per week. Patients were followed up for 40 weeks after completion of the exercise program. Both interventions produced similar improvements in the Chronic Respiratory Questionnaire dyspnea subscale at 1 year: improvement in dyspnea of 0.62 (95% CI: 0.43 to 0.80) units in the home intervention (n=107) and 0.46 (CI: 0.28 to 0.64) units in the outpatient intervention (n=109). The difference between treatments at 1 year was considered clinically unimportant. The study did not evaluate a comprehensive pulmonary rehabilitation program.

The trial reported by van Wetering and colleagues focused on patients with less advanced COPD. (11) They randomly assigned 199 patients with average moderate airflow obstruction but impaired exercise capacity (peak work load <70% predicted normal) to a 4-month PR program or usual care. At the end of the intervention, the PR group had significantly greater improvement in the SGRQ total score, a mean reduction of 3.9 points in the PR group, and an increase of 0.3 point in the usual care group. At 12 months, the SGRQ score had almost returned to baseline in the PR group; it remained stable in the usual care group. A total of 156 of 199 (79%) participants completed the 24-month follow-up. After 24 months, the total SGRQ score was slightly higher than baseline in the usual care group and lower than baseline in the PR group, a statistically significant 2.6 unit mean difference (p=0.045).

Patients with other chronic respiratory diseases

Patients with chronic lung diseases other than COPD have not been studied as extensively as those with COPD, in large part because the lower prevalence of these disorders. No RCTs evaluating comprehensive PR programs in this population were identified. There are several published case series and comparative observational studies. Case series included a 2006 retrospective study of 422 patients (309 with COPD and 113 with other forms of chronic lung disease) enrolled in a multidisciplinary PR program at a single medical center. (12) Of the non-COPD patients, 27 had asthma and 25 had restrictive disease. This study found similar improvements in the 6-minute walk and the Chronic Respiratory Questionnaire (CRQ) in both groups. In 2010, Kozu and colleagues compared outcomes in 2 cohorts of patients that participated in an identical 8-week outpatient PR program in Japan. (13) This prospective study included 45 patients with idiopathic pulmonary fibrosis (IPF), and these were matched by age and disease severity to 45 COPD patients. A total of 36 of 45 (80%) IPF patients and 40 of 45 (89%) completed the program. At the end of the program, each group experienced statistically significant increases in exercise capacity (distance walked in 6 minutes), improvement in dyspnea (lower dyspnea grade), and an increase in the activities of daily living (ADL) score compared to baseline. The COPD group, but not the IPF group, also had statistically significant increases in health status as measured by the short form-36 (SF-36). Six-month follow-up data were available for 30 of 45 (67%) of IPF patients and 37 of 45 (82%) of COPD patients. Comparing the 2 groups at 6 months, patients in the COPD group had significantly greater exercise capacity, greater improvement in dyspnea, and higher ADL scores compared to the IPF group.

In 2011, Ong and colleagues in Australia retrospectively compared findings in patients with bronchiectasis (n=69) and an age- and gender-matched group of patients with COPD who attended an outpatient PR program. (14) During the 12-month follow-up period, the 2 diagnosis groups did not differ significantly on the primary outcome measures, 6MWD (p=0.20) and score on the Chronic Respiratory Disease Questionnaire (p=0.7). At the 12-month follow-up, the mean between-group difference in the 6MWD was 16.1m (95% CI: -15.0 to 47.1), and the mean between-group difference in the CRQ was -1.3 points (95% CI: -10.1 to 8.3). This study was not designed to evaluate whether or not patients with bronchiectasis benefit from PR programs (e.g., it did not compare PR to usual care).

Conclusions: Multiple RCTs and meta-analyses of RCTs have found improved outcomes (i.e., functional ability and quality of life) in patients with moderate to severe COPD who undergo a comprehensive PR program in the outpatient setting. No published RCTs were identified in patients with chronic respiratory diseases other than COPD.

Repeat and maintenance pulmonary rehabilitation programs for patients with chronic pulmonary disease

Both repeat and maintenance PR programs provide additional rehabilitation services after initial participation in a PR program. Program categories are not strictly defined but repeat programs are generally considered to be those that include patients who failed to respond to an initial program or whose response to an initial rehabilitation program has diminished over time. In contrast, maintenance programs tend to be those designed to maintain the effects of the initial PR program, and they are open to all patients who successfully completed an initial program.

One RCT was identified that evaluated a repeat PR program. Carr and colleagues in Canada prospectively identified patients with moderate to severe COPD who experienced an acute exacerbation within 12 months of participating in a PR program. (15) Initially, patients completed either a 6-week inpatient program or a 12-week outpatient program. The repeat PR program lasted 3 weeks and consisted of exercise and education; patients could choose inpatient or outpatient versions. Over 6 months, a total of 41 patients developed an exacerbation and 12 did not have an exacerbation. Seven patients withdrew from the study, and the remaining 34 were randomly assigned to receive a repeat PR program within 1 month of the exacerbation (n=17) or no repeat PR program (n=17). One patient in the intervention group dropped out; of the remaining 33 patients, 25 (76%) experienced an exacerbation of moderate severity; the remaining 8 had severe exacerbations. Nine of 16 patients (56%) remaining in the intervention group chose an inpatient program and 7 chose an outpatient program. Patients were assessed before the repeat PR program, immediately after the program (3 weeks later), and again 12 weeks after the beginning of the exacerbation (approximately 5 weeks after completing the repeat rehabilitation program). The primary outcome was change in HRQOL as measured by the Chronic Respiratory Questionnaire (CRQ), a validated measure with 4 domains (dyspnea, fatigue, emotional function, and mastery). There was no statistically significant difference between groups in change in CRQ scores. Among patients in the intervention group, the magnitude of improvement in the domains of dyspnea (0.7 +/- 1.5 points) and fatigue (0.5 +/- 1.3 points) met or exceeded the minimum clinically important difference (MCID). In the control group, the magnitude of change in all dimensions did not meet the MCID. Change in the 6MWD, a secondary outcome, was not significantly different between groups at either follow-up time. Outcomes were not reported separately for patients who chose inpatient versus outpatient programs (the policy addresses outpatient programs). The authors recommended that future evaluations of repeat PR programs include patients with more serious exacerbations, last longer than 3 weeks, and start as close in time as possible to the exacerbation. Conclusions about repeat PR programs cannot be drawn from one study with a small sample size.

In 2012, an Ontario Health Technology Assessment was published on pulmonary rehabilitation for patients with COPD. (16) The review identified 3 RCTs (total of 284 participants) evaluating maintenance PR programs for individuals with COPD who successfully completed an initial PR program. The studies excluded patients who had experienced a recent acute exacerbation of COPD. The maintenance programs all consisted of supervised exercise sessions; program duration was 3 months in 1 program and 12 months in the other 2 programs. One program also included an unsupervised exercise component, and 1 included educational sessions. The reviewers judged the quality of the studies as generally poor due to methodologic limitations such as inadequate information on randomization, allocation concealment and blinding and lack of clarity around the use of an intention-to-treat (ITT) analysis. In a pooled analysis of data from 2 of the studies (total n=168), there was a significantly greater 6 minute walk distance in patients who participated in the maintenance program compared to those in a control group (mean difference: 22.9 meters [95% CI: 5.2 to 40.7]). The confidence interval was wide, indicating lack of precision in the pooled estimate. In addition, the review authors considered the minimal clinically important difference in meters walked to be 25-35 meters, and the meta-analysis of study findings did not meet this threshold of difference between groups.

Conclusions: A few small RCTs have been performed that evaluate repeat or maintenance rehabilitation programs. Due to the small number of RCTs, methodologic limitations of available studies, and lack of clinically significant findings, the evidence to determine the effect of repeat and maintenance PR programs on health outcomes in patients with COPD is insufficient.

Preoperative candidates for lung volume reduction or lung transplantation

Pulmonary rehabilitation prior to lung volume reduction surgery (LVRS) represents a distinct subset of patients with COPD, and the National Emphysema Treatment Trial (NETT) requires all candidates to undergo a vigorous course of PR. The final results of the NETT Trial support treatment effectiveness in a subset of patients with COPD. (17)

Several small RCTs have been published evaluating preoperative pulmonary rehabilitation for patients undergoing lung cancer resection. In 2012, Morano and colleagues published a single-blind study that was conducted in Brazil. (18) Patients were randomly assigned to receive 4 weeks of pulmonary rehabilitation (exercise-only, 5 sessions per week) or chest physical therapy; there were 12 patients in each group. All patients in the PR group and 9 of 12 in the chest physical therapy group subsequently underwent surgery (the other 3 patients were found to have inoperable disease). Several postoperative outcomes were assessed. Patients in the PR group spent significantly fewer days in the hospital than patients in the chest physical therapy group (mean of 7.8 vs. 12.2 days, p=0.04). In addition, patients in the PR group spent fewer days with chest tubes than the physical therapy group (mean of 4.5 vs. 7.4 days, p=0.03). There was not a significant difference between groups in the length of hospital stay. The study did not assess longer-term functional outcomes after surgery.

In 2011, Benzo and colleagues published findings of 2 small exploratory RCTs evaluating pulmonary rehabilitation prior to lung cancer resection. (19) Eligibility criteria included having moderate to severe COPD and being scheduled for lung cancer resection either by open thoracotomy or video-assisted thoracoscopy. The first study had poor recruitment and was only able to enroll 9 patients. The second study enrolled 19 patients in either a 10-session pre-operative PR program (n=10) or usual care (n=9). The mean number of days in the hospital was 6.3 (standard deviation [SD]=3.0) in the PR group and 11.0 (SD=6.3) in the control group; p=0.058. A total of 3 patients (33%) in the PR group and 5 patients (63%) in the control group experienced post-operative pulmonary complications; p=0.23. The study likely had too small a sample size to detect statistically and clinically significant differences between groups. The authors recommended that a larger multicenter randomized trial be conducted in this population of patients.

Conclusions: There is a lack of large RCTs comparing PR to no PR for preoperative candidates undergoing LVRS, lung transplantation, or lung cancer resection. However, the National Emphysema Trial (NETT) required PR prior to lung volume reduction surgery: PR is standard of care prior to LVRS and lung transplantation. The few small RCTs published to date on PR prior to lung cancer resection did not find consistent evidence of benefit.

Ongoing Clinical Trials

Pulmonary Rehabilitation in Interstitial Lung Diseases (NCT00882817): (20) This trial is randomizing patients with interstitial lung disease to receive 6 months of pulmonary rehabilitation or usual care. The primary study outcome is change in the six minute walk distance after 6 months. The study is sponsored by Katholieke Universiteit Leuven in Belgium, and the expected sample size is 60 patients.

Effects of Home-based Pulmonary Rehabilitation in Patients With Severe or Very Severe Chronic Obstructive Pulmonary Disease (COPD) (NCT01198288) (21): The study, conducted in Italy, is randomizing patients with COPD to receive standard care only (medication, information about exercise, and monthly check-in calls) or standard care plus 10 in-home supervised pulmonary rehabilitation sessions. The primary outcome is the distance walked test, and secondary outcomes include quality of life, dyspnea, and COPD relapse rate. Estimated enrollment is 182 patients. The study is sponsored by the Associazione Riabilitatori Insufficienza Respiratoria.

Summary

The literature supports the conclusion that a comprehensive pulmonary rehabilitation (PR) program in the outpatient ambulatory care setting in patients with moderate to severe chronic respiratory disease is associated with improved symptoms and quality of life. Although there have been many randomized trials, the structure of PR programs is variable, so no further guidance is available regarding the components of an optimal PR program or its duration. There are insufficient data that a comprehensive home-based PR program improves the net health outcome compared to no PR or PR provided in the ambulatory care setting. Thus, a single course of PR may be considered medically necessary in the ambulatory care setting for patients with moderate to severe chronic pulmonary disease who meet criteria and investigational in the home setting. There are insufficient data focusing on programs designed to maintain the benefits of a PR program or evaluate repeat PR programs. Thus, repeat and maintenance PR programs are considered investigational.

For patients undergoing lung surgery, findings from the National Emphysema Treatment Trial suggest a subset of COPD patients who are appropriate candidates for PR prior to lung surgery. Therefore a single course of PR in an outpatient setting is considered medically necessary for patients prior to lung resection surgery. For patients undergoing lung transplantation, PR is considered standard of care to maximize preoperative pulmonary status, and PR may be considered medically necessary for these patients. For patients undergoing lung cancer resection, there are a few small RCTs but these trials have not demonstrated a consistent benefit on clinical outcomes. PR is considered investigational for patients undergoing lung cancer resection.

Practice Guidelines and Position Statements

A 2011 joint guideline on management of COPD was issued from the American College of Physicians (ACP), the American College of Chest Physicians (ACCP), the American Thoracic Society (ATS), and the European Respiratory Society (ERS) (22): The guideline recommends that “clinicians should prescribe pulmonary rehabilitation for symptomatic patients with an [forced expiratory volume] FEV <50% predicted (Grade: strong recommendation, moderate-quality evidence). Clinicians may consider pulmonary rehabilitation for symptomatic or exercise-limited patients with an FEV >50% predicted (Grade: weak recommendation, moderate-quality evidence).”

In 2007, a joint guideline on pulmonary rehabilitation was issued by the American College of Chest Physicians (ACCP) and the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) (3): The panel issued a number of recommendations. Following are the strong recommendations based on strong (1A) or moderate (1B) evidence:

Grade of Recommendation 1A

  • A program of exercise training of the muscles of ambulation is recommended as a mandatory component of pulmonary rehabilitation for patients with chronic obstructive pulmonary disease.
  • Pulmonary rehabilitation improves the symptom of dyspnea and improves HRQOL in patients with COPD.
  • Six to 12 weeks of pulmonary rehabilitation produces benefits in several outcomes that decline gradually over 12 to 18 months.
  • Both low- and high-intensity exercise training produce clinical benefits for patients with COPD. Unsupported endurance training of the upper extremities is beneficial in patients with COPD and should be included in pulmonary rehabilitation programs.

Grade of Recommendation 1B

  • Lower-extremity exercise training at higher exercise intensity produces greater physiologic benefits than lower-intensity training in patients with COPD. The scientific evidence does not support the routine use of inspiratory muscle training as an essential component of pulmonary rehabilitation.
  • Education should be an integral component of pulmonary rehabilitation. Education should include information on collaborative self-management and prevention and treatment of exacerbations.
  • Pulmonary rehabilitation is beneficial for some patients with chronic respiratory diseases other than COPD.

References:

 

  1. Nici L, Donner C, Wouters E et al. American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation. Am J Respir Crit Care Med 2006; 173(12):1390-413.
  2. Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Pulmonary rehabilitation for patients with chronic obstructive pulmonary disease. TEC Assessments 1996; Volume 11, Tab 4.
  3. Ries AL, Bauldoff GS, Carlin BW et al. Pulmonary rehabilitation: joint ACCP/AACVPR evidence-based clinical practice guidelines. Chest 2007; 131(5 suppl):4S-42S.
  4. Puhan M, Gimeno-Santos E, Scharplatz M et al. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2011; (10):CD005305.
  5. Vieira D, Maltais F, Bourbeau J. Home-based pulmonary rehabilitation in chronic obstructive pulmonary disease patients. Curr Opin Pulm Med 2010; 16(2):134-43.
  6. Beauchamp MK, Janaudis-Ferreira T, Goldstein RS et al. Optimal duration of pulmonary rehabilitation for individuals with chronic obstructive pulmonary disease- a systematic review. Chron Respir Dis 2011; 8(2):129-40.
  7. Guell R, Casan P, Belda J et al. Long-term effects of outpatient rehabilitation of COPD: a randomized trial. Chest 2000; 117(4):976-83.
  8. Griffiths TL, Burr ML, Campbell IA et al. Results at 1 year of outpatient multidisciplinary pulmonary rehabilitation: a randomised controlled trial. Lancet 2000; 355(9201):362-8.
  9. Wedzicha JA, Bestall JC, Garrod R et al. Randomized controlled trial of pulmonary rehabilitation in severe chronic obstructive pulmonary disease patients, stratified with the MRC dyspnoea scale. Eur Respir J 1998; 12(2):363-9.
  10. Maltais F, Bourbeau J, Shapiro S et al. Effects of home-based pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: a randomized trial. Ann Intern Med 2008; 149(12):869-78.
  11. van Wetering C.R., Hoogendoorn M., Mol SJ et al. Short- and long-term efficacy of a community-based COPD management program in less advanced COPD: a randomised controlled trial. Thorax 2010; 65(1):7-13.
  12. Ferreira G, Feuerman M, Spiegler P. Results of an 8-week, outpatient pulmonary rehabilitation program on patients with and without chronic obstructive pulmonary disease. J Cardiopulm Rehabil 2006; 26(1):54-60.
  13. Kozu R, Senjyu H, Jenkins SC et al. Differences in response to pulmonary rehabilitation in idiopathic pulmonary fibrosis and chronic obstructive pulmonary diseases. Respiration 2011; 81(3):196-205.
  14. Ong HK, Lee AL, Hill CJ et al. Effects of pulmonary rehabilitation in bronchiectasis: a retrospective study. Chronic Respir Dis 2011; 81(1):21-30.
  15. Carr SJ, Hill K, Brooks D et al. Pulmonary rehabilitation after acute exacerbation of chronic obstructive pulmonary disease in patients who previously completed a pulmonary rehabilitation program. J Cardiopulmon Rehab Prev 2009; 29(5):318-24.
  16. Health Quality Ontario. Ontario Health Technology Series: Pulmonary rehabilitation for patients with chronic pulmonary disease (COPD): An evidence-based analysis. 2012. Available online at: www.hqontario.ca. Last accessed December, 2012.
  17. Fishman A, Martinez F, Naunheim K et al. A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema. N Engl J Med 2003; 348(21):2059-73.
  18. Morano MT, Araujo AS, Nascimento FB et al. Preoperative pulmonary rehabilitation versus chest physical therapy in patients undergoing lung cancer resection: a pilot randomized controlled trial. Arch Phys Med Rehabil 2013; 94(1):53-8.
  19. Benzo R, Wigle D, Novotny P et al. Preoperative pulmonary rehabilitation before lung cancer resection: Results from two randomized studies. Lung Cancer 2011; 74(3):441-5.
  20. Sponsored by Katholieke Universiteit Leuven (Belgium). Pulmonary Rehabilitation in Interstitial Lung Diseases (NCT00882817). Available online at: www.clinicaltrials.gov. Last accessed December, 2012.
  21. Sponsored by Associazione Riabilitatori Insufficienza Respiratoria (Italy). Effects of Home-based Pulmonary Rehabilitation in Patients With Severe or Very Severe Chronic Obstructive Pulmonary Disease (COPD) (NCT01198288). Available online at: www.clinicaltrials.gov. Last accessed December, 2012.
  22. Qaseem A, Wilt TJ, Weinberger SE et al. Diagnosis and management of stable chronic obstructive disease: A clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and the European Respiratory Society. Ann Intern Med 2011; 155(3):179-91.

Codes

Number

Description

CPT  No Code 
ICD-9 Procedure  93.18  Breathing exercise 
  93.19  Exercise, not elsewhere classified 
  94.49  Other counseling 
ICD-9 Diagnosis  135; 517.8 Sarcoidosis
  235.7 Lymphangiomyomatosis
  277.00-277.01 Cystic fibrosis (both lungs to be transplanted)
  277.6 Alpha-1 antitrypsin deficiency
  277.8 Eosinophilic granuloma
  402.10 Pumonary hypertension due to cardiac disease
  415.1 Recurrent pulmonary embolism
  416.0 Primary pulmonary hypertension
  491.20 Obstructive chronic bronchitis without exacerbation
  491.8 Bronchiolitis obliterans
  492.0, 492.8 Emphysema
  494 (748.61 for congenital) Bronchiectasis
  496 Chronic airway obstruction, not elsewhere classified
  515 Interstitial pulmonary fibrosis
  516.3 Idiopathic pulmonary fibrosis
  710.1 Scleroderma
  745.4 Eisenmenger's syndrome
  770.7 Bronchopulmonary dysplasia
HCPCS  G0237, G0238, G0239  Codes for therapeutic procedures to improve respiratory function or increase strength or endurance or respiratory muscles  
  G0302, G0303, G0304, G0305   Codes for pre-operative and post-discharge outpatient services related to lung volume reduction surgery 
  G0424 Pulmonary rehabilitation, including exercise (includes monitoring), one hour, per session, up to 2 session per day (new code 1/1/10)
  S9473  Pulmonary rehabilitation program, nonphysician provider, per diem 
ICD-10-CM (effective 10/1/14) J99 Respiratory disorders in diseases classified elsewhere
   D86.0-D86.9 Sarcoidosis; code range
   D38.0-D38.6 Neoplasm of uncertain behavior of middle ear and respiratory and intrathoracic organs; code range
   E84.0-E84.9 Cystic fibrosis; code range
   D84.1 Defects in the complements system
   C96.6 Unifocal Langerhans-cell histiocytosis
   I11.0-I11.9 Hypertensive heart disease; code range
   Z86.71 Personal history of pulmonary embolism
   I27.0 Primary pulmonary hypertension
  J44.0-J44.9 Other Chronic obstructive pulmonary disease; code range
  J41.0-J41.8 Simple and mucopurulent chronic bronchitis; code range
   J43.0-J43.9 Emphysema; code range
   J47.0-J47.9 Bronchiectasis; code range
   J84.0-J84.9 Other interstitial pulmonary diseases
   M34.0-M34.9 Systemic sclerosis (scleroderma); code range
   Q21.0 Ventricular septal defect (Eisenmenger’s syndrome)
   P27.0-P27.9 Chronic respiratory disease originating in the perinatal period; code range
ICD-10-PCS (effective 10/1/14)   Not applicable. Policy is only for outpatient services.
Type of Service  Therapy 
Place of Service  Outpatient 
Home
 


Index

Pulmonary Rehabilitation
Rehabilitation, Pulmonary  


Policy History

Date Action Reason
07/31/96 Add to Therapy section: Rehabilitation subsection New policy
07/12/02 Replace policy Policy reviewed; expanded rationale and references; policy statement is unchanged
12/17/03 Replace policy Policy updated with literature search; policy statement unchanged
03/15/05 Replace policy Policy updated with literature search; policy statement unchanged
12/14/05 Replace policy Policy updated with literature search; policy statement unchanged. No further scheduled review
4/25/06 Replace policy – error correction only Code table updated with HCPCS codes G0237-G0239 and S9473.
1/08/09 Replace policy  Policy updated with literature review, reference number 20 added. No change in policy statements
02/11/10 Replace policy Policy updated with literature review; rationale extensively rewritten; references 1, 5, 11 added; other references renumbered/removed. No change in policy statements.
2/10/11 Replace policy Policy updated with literature review. References 6, 12, 15 and 16 added; other references renumbered/removed. Policy statement on home-based pulmonary rehabilitation programs added; existing medically necessary policy statements edited to clarify that outpatient programs refer to those in the ambulatory care setting.
1/12/12 Replace policy Policy updated with literature review. References 4, 6, 16, 18-21 16 added; other references renumbered or removed. No change in policy statements.
9/21/12 policy updated - Local GOLD standard used to determine severity of disease
1/10/13 Replace policy
Policy updated with literature review. References 16, 18 and 21 added; other references renumbered or removed. No change in policy statements.