Knowledge Base Article

I do not usually write articles about Medicare Coverage Decision Memorandums. This is because Coverage Decision Memos are not binding on contractors or Administrative Law Judges (ALJs) until they are implemented in a CMS-issued program instruction. Formal program instructions are supposed to occur within 180 days of the end of the calendar quarter in which the memo was posted on the Web site. If there are specific coding and billing instructions, they will also be published at the same time in a transmittal that updates the Medicare Claims Processing manual. The effective date of Medicare coverage of a particular service finalized in a National Coverage Determination (NCD) appears to always be made retroactive back to the date of the decision memo. So although the coverage of a service begins at the time of the Decision Memo, providers shouldn’t attempt to bill for the service until a final NCD and any associated billing/coding instructions are released.

This time I am going to make an exception because I think it is very interesting and an excellent Medicare benefit that CMS has decided to cover exercise therapy for patients with peripheral artery disease (PAD). PAD is the buildup of plaque in the arteries causing narrowing and affecting the lower extremities. Approximately 12% of Americans have PAD, but the prevalence increases with age. PAD causes pain and discomfort in the legs when walking or exercising but resolves with rest. This is known as intermittent claudication (IC). IC can dramatically affect patients’ functional independence and quality of life. As with all things Medicare, the minutiae are in the explanation of the coverage requirements.

Medicare will cover supervised exercise therapy (SET) when the following requirements are met:

• For beneficiaries with intermittent claudication (IC) for the treatment of symptomatic peripheral artery disease (PAD);
• Up to 36 sessions over a 12 week period;
• Sessions lasting 30-60 minutes comprising a therapeutic exercise-training program for PAD in patients with claudication;
• In a hospital outpatient setting, or a physician’s office;
• Delivered by qualified auxiliary personnel trained in exercise therapy for PAD to ensure benefits exceed harms; and
• Under the direct supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist trained in both basic and advanced life support techniques.

The patient must have a face-to-face visit with and obtain a referral for the SET from the physician treating their PAD. At this visit, the patient must receive information on cardiovascular disease and PAD risk factor reduction. This could include education, counseling, behavioral interventions, and outcome assessments. The Medicare Administrative Contractor may approve 36 additional sessions of SET for PAD based on a second referral. Medicare will not cover SET if a patient’s primary physician determines the patient has an absolute contraindication to exercise.

Exercise therapy is an effective way to alleviate the pain of PAD. SET may also prevent the progression of PAD and lower the risk of cardiovascular events that are prevalent in these patients. Greater access to SET programs could decrease the need for endovascular revascularization (ER) procedures so that ER can be reserved for cases where the patient is too functionally impaired for SET.

Providers should be on the lookout for the NCD and any associated claims processing instructions related to this decision memo.