Peripheral Artery Disease (PAD) Rehabilitation - Paramount Health Care

Peripheral Artery Disease (PAD) Rehabilitation

Policy Number: PG0414 Last Review: 04/26/2018

ADVANTAGE | ELITE | HMO INDIVIDUAL MARKETPLACE |

PROMEDICA MEDICARE PLAN | PPO

GUIDELINES This policy does not certify benefits or authorization of benefits, which is designated by each individual policyholder contract. Paramount applies coding edits to all medical claims through coding logic software to evaluate the accuracy and adherence to accepted national standards. This guideline is solely for explaining correct procedure reporting and does not imply coverage and reimbursement.

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 45 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 postsurgical 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.

Peripheral artery disease rehabilitation is considered not medically necessary because there is insufficient peerreviewed scientific literature that demonstrates the procedure/service is effective.

POLICY Peripheral Artery Disease (PAD) Rehabilitation (93668) is non-covered for HMO, PPO, Individual Marketplace, & Advantage.

Peripheral Artery Disease (PAD) Rehabilitation (93668) requires prior authorization for Elite/ProMedica Medicare Plan.

PG0414 ? 12/28/2020

COVERAGE CRITERIA HMO, PPO, Individual Marketplace, Advantage Peripheral arterial disease rehabilitative exercise is considered not medically necessary as there is insufficient peer reviewed, scientifically controlled studies in the literature which demonstrate the superior outcomes of such programs over exercise without supervision.

Elite/ProMedica Medicare Plan Supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) is covered up to 36 sessions over a 12-week period if ALL of 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 patients with claudication

Be conducted in 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 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.

SET is non-covered for members with absolute contraindications to exercise as determined by their primary physician.

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

ICD-10 CODES

I70.211 Atherosclerosis of native arteries of extremities with intermittent claudication, right leg

I70.212 Atherosclerosis of native arteries of extremities with intermittent claudication, left leg

I70.213 Atherosclerosis of native arteries of extremities with intermittent claudication, bilateral legs

I70.218 Atherosclerosis of native arteries of extremities with intermittent claudication, other extremity

I70.311

Atherosclerosis of unspecified type of bypass graft(s) of the extremities with intermittent claudication, right leg

I70.312

Atherosclerosis of unspecified type of bypass graft(s) of the extremities with intermittent claudication, left leg

I70.313

Atherosclerosis of unspecified type of bypass graft(s) of the extremities with intermittent claudication, bilateral legs

I70.318

Atherosclerosis of unspecified type of bypass graft(s) of the extremities with intermittent claudication, other extremity

I70.611

Atherosclerosis of nonbiological bypass graft(s) of the extremities with intermittent claudication, right leg

I70.612

Atherosclerosis of nonbiological bypass graft(s) of the extremities with intermittent claudication, left leg

I70.613

Atherosclerosis of nonbiological bypass graft(s) of the extremities with intermittent claudication, bilateral legs

PG0414 ? 12/28/2020

I70.618 I70.711 I70.712 I70.713 I70.718

Atherosclerosis of nonbiological bypass graft(s) of the extremities with intermittent claudication, other extremity Atherosclerosis of other type of bypass graft(s) of the extremities with intermittent claudication, right leg Atherosclerosis of other type of bypass graft(s) of the extremities with intermittent claudication, left leg Atherosclerosis of other type of bypass graft(s) of the extremities with intermittent claudication, bilateral legs Atherosclerosis of other type of bypass graft(s) of the extremities with intermittent claudication, other extremity

REVISION HISTORY EXPLANATION ORIGINAL EFFECTIVE DATE: 10/27/2017 10/27/17: Peripheral Artery Disease (PAD) Rehabilitation (93668) is non-covered for HMO, PPO, Individual Marketplace, & Advantage. 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). 03/22/18: Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG). 04/26/18: 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). 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

REFERENCES/RESOURCES Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services Ohio Department of Medicaid 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 Industry Standard Review Hayes, Inc.

PG0414 ? 12/28/2020

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