Cardiac Rehabilitation: Outpatient (CPB 0021, reviewed 2026-03-10)

By March 10, 2026: Billing team must update billing software and prior authorization protocols to enforce Aetna's cardiac rehabilitation coverage rules: (1) CPT 93797 and 93798 require eligible diagnosis within 12-month window (reference policy's 15-item eligibility list); (2) Maximum 36 sessions per 12-month period, with additional 36 sessions only for members with subsequent qualifying cardiovascular events; (3) Flag claims for CPT 92997/92998 as non-covered for cardiac rehabilitation indications; (4) Implement telehealth validation rules for CPT 93797/93798 when telehealth criteria are met (low-risk members with LVEF >50%, no complex arrhythmias, functional capacity ≥7 METs, safe home environment with reliable internet); (5) Deny claims for cardiac rehabilitation following pericardiectomy for calcified constrictive pericarditis and all experimental/investigational conditions listed in policy (e.g., atrial fibrillation ablation, POTS, hypertrophic cardiomyopathy, post-chemotherapy cardiotoxicity prevention); (6) Update encounter forms and provider education materials to require documentation of qualifying diagnosis, functional capacity, and supervision availability. Providers must document medical necessity at time of service. Claims submitted without meeting these criteria will be denied. Billing staff should cross-reference qualifying diagnoses ICD-10 codes against the 15 eligible conditions in the policy eligibility section.