Peripheral Artery Disease (PAD) Rehabilitation - Paramount Health Care

Medical Policy

Peripheral Artery Disease (PAD) Rehabilitation

Policy Number: PG0414 Last Review: 12/01/2023

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GUIDELINES: ? This policy does not certify benefits or authorization of benefits, which is designated by each individual

policyholder terms, conditions, exclusions, and limitations contract. It does not constitute a contract or guarantee regarding coverage or reimbursement/payment. Self-Insured group specific policy will supersede this general policy when group supplementary plan document or individual plan decision directs otherwise. ? Paramount applies coding edits to all medical claims through coding logic software to evaluate the accuracy and adherence to accepted national standards. ? This medical policy is solely for guiding medical necessity and explaining correct procedure reporting used to assist in making coverage decisions and administering benefits.

SCOPE: X Professional X Facility

DESCRIPTION: Peripheral arterial disease (PAD) is a common chronic cardiovascular condition that affects the lower extremities and can substantially limit daily activities and quality of life. Lifestyle interventions, including smoking cessation, diet modification, regular physical activity, and pharmacotherapy, are often prescribed to treat patients with PAD.

Peripheral vascular rehabilitative physical exercise consists of a series of sessions, lasting 30 to 60 minutes per session, involving use of either a motorized treadmill or a track to permit the patient to achieve symptom-limited claudication. Each session is supervised on a one-on-one basis by an exercise physiologist, physical therapist, or nurse. The supervising provider monitors the individual patient's claudication threshold and other cardiovascular limitations for adjustment of workload. During this supervised rehabilitation program, the development of new arrhythmias, symptoms that might suggest angina, or the continued inability of the patient to progress to an adequate level of exercise may require physician review and examination of the patient.

Both physical activity and medications are used to treat peripheral vascular disease. Vascular specialists agree that long daily walks are the best treatment for people with intermittent claudication, thereby increasing the distance of pain-free walking through the development of collateral circulation. Patients whose legs hurt during physical activity often find it hard to follow a walking program. For this reason, the cardiac rehabilitation departments of some hospitals have created supervised exercise programs that offer support and encouragement. These peripheral vascular rehabilitation programs are geared to patients with various peripheral vascular disorders, including post-surgical patients (e.g., peripheral angioplasty, peripheral arterial bypass, stent) and patients with peripheral arterial disease who are not candidates for surgery. Services are provided by a multi-disciplinary team, which includes nurses, physical therapists, and physicians. The usual duration of the program is 3 times a week for 12 weeks (36 visits). The goal of treatment is to improve endurance and decrease symptoms.

POLICY: Paramount Commercial Insurance ? Effective 01/01/2024 Peripheral Artery Disease (PAD) Rehabilitation (93668) is covered with a prior authorization Elite (Medicare Advantage) Plans ? Peripheral Artery Disease (PAD) Rehabilitation (93668) requires prior authorization

PG0414-02/01/2024

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COVERAGE CRITERIA: Paramount Commercial Insurance Plans and Elite (Medicare Advantage) Plans Paramount will cover Supervised Exercise Therapy (SET) for symptomatic peripheral artery disease (PAD) with intermittent claudication (IC) for the treatment of symptomatic PAD, characterized by fatigue, discomfort, cramping or pain of vascular origin in the muscles of the lower extremities that is consistently caused by exercise and consistently relieved by rest (within 10 minutes).

SET for symptomatic PAD is covered up to 36 sessions over a 12-week period if ALL the following components of a SET program are met:

? Consist of sessions lasting 30-60 minutes comprising a therapeutic exercise-training program for PAD in members with claudication

? Be conducted in a hospital outpatient setting, or a physician's office ? Be delivered by qualified auxiliary personnel necessary to ensure benefits exceed harms, and who are

trained in exercise therapy for PAD ? Be under the direct supervision of a physician, physician assistant, or nurse practitioner/clinical nurse

specialist who must be trained and holds a current certification in both basic and advanced life support techniques ? Members must have a face-to-face visit with the physician responsible for PAD treatment to obtain the referral for SET. At this visit, the member must receive information regarding cardiovascular disease and PAD risk factor reduction, which could include education, counseling, behavioral interventions, and outcome assessments.

A second prior authorization referral is required for additional sessions beyond 36 sessions. An attestation would be needed from the referring provider of the services stating that documentation is on file verifying that further treatment beyond the 36 sessions of SET over a 12-week period meets the requirements of the medical policy.

Limitations: ? SET is non-covered for members with absolute contraindications to exercise as determined by their primary physician. ? Critical/chronic limb ischemia (CLI) characterized by chronic (greater than two weeks) ischemic rest pain, nonhealing wound/ulcers or gangrene in one or both legs attributable to objectively proven arterial occlusive disease. ? Members with absolute contraindications to exercise as determined by their primary physician.

Experimental and Investigational: The following peripheral vascular rehabilitation programs are considered experimental and investigational because the effectiveness of these approaches has not been established:

? PADnet System and testing program for evaluation of peripheral artery disease (PAD) and other indications;

? QuantaFlo System for screening of PAD. Note: Measurement of ankle brachial index (ABI) is considered integral to the evaluation and management service and is not separately reimbursed;

? Transcutaneous visible light hyperspectral imaging (HyperView) for determination of oxygenation levels in superficial tissues for individuals with potential circulatory compromise (e.g., peripheral vascular disease) and all other indications.

CODING/BILLING INFORMATION: The appearance of a code in this section does not necessarily indicate coverage. Codes that are covered may have selection criteria that must be met. Payment for supplies may be included in payment for other services rendered.

CPT CODE 93668 Peripheral arterial disease (PAD) rehabilitation, per session

PG0414-02/01/2024

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REVISION HISTORY EXPLANATION: ORIGINAL EFFECTIVE DATE: 10/27/2017

Date

Explanation & Changes

? Peripheral Artery Disease (PAD) Rehabilitation (93668) is non-covered for HMO, PPO,

Individual Marketplace, & Advantage

10/27/2017

? Peripheral Artery Disease (PAD) Rehabilitation (93668) is covered with prior authorization for Elite

? Policy created to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG)

03/22/2018

? Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG)

? Policy revised per CMS guidelines effective 07/02/18

? The SET program for PAD must be provided in a physician's office (Place of Service

code 11)

04/26/2018

? Removed ICD-10 code I70.219 ? Added ICD-10 codes I70.31, I70.312, I70.313, I70.318, I70.611, I70.612, I70.613,

I70.618, I70.711, I70.712, I70.713, & I70.718

? Policy reviewed and updated to reflect most current clinical evidence per The Technology

Assessment Working Group (TAWG)

12/28/2020

? Medical policy placed on the new Paramount Medical policy format

03/02/2023

? Medical Policy updated to reflect Medicaid coverage to Anthem as of 02/01/2023

? Medical Policy reviewed and updated to reflect the most current clinical evidence

12/01/2023

? Added coverage for the Paramount Commercial Insurance plans, effective 01/01/2024

? Removed the ICD-10 diagnosis codes

02/01/2024

? Medical Policy placed on the new policy format

Paramount reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to

REFERENCES/RESOURCES Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and

services

American Medical Association, Current Procedural Terminology (CPT?) and associated publications and services

Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Release and Code Sets

U.S. Preventive Services Task Force, Industry Standard Review

Hayes, Inc.,

Industry Standard Review

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