Janea. I called my insurance today and got the same thing about not being covered for a valve replacement. The insurance people told me to have the cardiologist "write a letter of medical necessity requesting pre-authorization for cardiac rehab". So I called the cardio and was told by the nurse, that Medicare, for the first time in 10 years!! has revised it's coverage and added several diagnoses -- one of which is valve replacemnt. SO assuming your insurance uses medicare guidelines, they are behind the times and need YOU to tell them to get up to date and give you the coverage.
I googled 2006 medicare guidelines for cardiac rehab and got these......
Marguerite
http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=164
CMS revises the language in Manual 100-3 § 20.10 to read as follows:
A. General
Phase II cardiac rehabilitation, as described by the U.S. Public Health Service, is a comprehensive, long-term program including medical evaluation, prescribed exercise, cardiac risk factor modification, education, and counseling. Phase II refers to outpatient, medically supervised programs that are typically initiated 1-3 weeks after hospital discharge and provide appropriate electrocardiographic monitoring.
B. Nationally Covered Indications
Effective for services performed on or after March 22, 2006, Medicare coverage of cardiac rehabilitation programs are considered reasonable and necessary only for patients who: (1) have a documented diagnosis of acute myocardial infarction within the preceding 12 months; or (2) have had coronary bypass surgery; or (3) have stable angina pectoris; or (4) have had heart valve repair/replacement; or (5) have had percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting; or (6) have had a heart or heart-lung transplant.
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http://www.cscr.org/Elgblty.htm
Phases of Cardiac Rehabilitation
Phase I Cardiac Rehabilitation: Inpatient education and early ambulation
Phase II Cardiac Rehabilitation: Outpatient supervised telemetry monitored exercise, education, and lifestyle modification counseling.
Phase III Cardiac Rehabilitation: Supervised non-telemetry monitored exercise and education.
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Special Population Programs
Pulmonary Rehabilitation
Vascular Improvement Programs: Exercise designed for people suffering from claudication.
Renal Exercise Programs: Exercise designed for people with kidney disease.
Diabetic Exercise Programs: Designed for people with diabetes Type I and II.
Please note most programs require a physician referral. Contact your local Cardiac Rehabilitation Center for information on what programs they offer.
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Cardiac Rehabilitation Eligibility
Medicare has developed specific guidelines regarding eligibility for Cardiac Rehabilitation. The Federal Agency that did oversee Medicare was the Health Care Financing Administration. The Centers for Medicare and Medicaid Services (CMS) now does so. Their web address is
http://cms.hhs.gov/ Type in-cardiac rehabilitation- in the search window for more information. It is important to note that Medicare is administered through local or regional insurance companies, known as Intermediaries. The Fiscal Intermediary (FI) for California has this web address
http://www.ugsmedicare.com.These Intermediaries follow the Medicare guidelines closely but some exceptions may occur. Your Cardiac Rehabilitation professional should be able to tell you if you have Cardiac Rehab benefits. The CMS Decision Memo of March 22, 2006 states Medicare will cover people with the following conditions:
1. Acute myocardial infarction (AMI)
2. Coronary artery bypass graft (CABG)
3. Stable angina pectoris
4. Heart valve repair or replacement
5. Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting
6. Heart or heart lung transplant.
This is not yet official. Go the following web page on the CMS web site for the entire document.
http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=164
Many insurance companies cover Cardiac Rehabilitation, but often restriction do apply. Other cardiac diagnoses (other than the three covered by Medicare) might be covered. Be an informed consumer. Confirm your benefits and know exactly to what you are entitled.
It has been the experience of many patients that non-Medicare HMOs are more generous in their coverage. Expressing your desire to your doctor and having an authorization request will set the process in motion.
To enter a program you will need a physician referral. Usually this can be obtained from your cardiologist or primary care physician. You may have to bring up the issue of Cardiac Rehabilitation with your physician. Many programs require you to have an exercise stress test before entering the program. This is to accurately determine what amount of exercise is safe for you. Cardiac Rehabilitation programs are individualized, meaning you will work at your own level under the supervision of trained Cardiac Rehabilitation professionals. Exercise is only one important component of the Cardiac Rehabilitation experience. For more detailed information about clinical practice guidelines in Cardiac Rehabilitation, go to the AHCPR homepage.
http://www.ahcpr.gov. Click on the search button. Type-cardiac rehabilitation- in the search window for more information.
