Karen Lui, RN, MS, MAACVPR

How to Implement a
Heart Failure Rehabilitation ProgramRegulatory & Eligibility Considerations
Karen Lui, RN, MS, MAACVPR
Denver - September 5, 2014
[email protected]
I have no disclosures.
• New Medicare coverage regulation
• Clinical interpretation of CMS
eligibility criteria
• FAQs & Clinical vignettes
Who is This “New” Patient
• Private payers have covered CR for
heart failure patients for years.
• HF patients with eligible dx have
participated in CR for years.
• HF patients have been treated in
maintenance settings for years.
Eligibility Criteria
“…beneficiaries with stable, chronic heart
failure, defined as patients with
– left ventricular ejection fraction of 35%
or less and,
– New York Heart Association (NYHA)
class II-IV symptoms despite being on
optimal heart failure therapy for at
least 6 weeks.”
NCD 20.10.1
Eligibility Criteria
“Stable patients are defined as patients
who have not had recent (< 6 weeks)
or planned (< 6 months) major
cardiovascular hospitalizations or
NCD 20.10.1
What Does That Mean?
• HF symptoms are not worsening such that
prompt evaluation for hospitalization is needed
Optimal therapy
• Guideline-based heart failure therapy
• Re-assessment & medication adjustment,
based on patient response and effective control
of symptoms
Eligibility Criteria-Bottom Line
• Each MAC has authority to interpret CMS criteria
and deny payment based on that interpretation.
• The CR Medical Director serves an essential role in
HF eligibility decisions.
• Medical necessity, dept policies, Medical Director
communication with referring MD, and collaborative
clinical judgment should guide referral
How often/how many times is a patient eligible for a
CR course?
• Eligibility for CR is “per indication”
– CMS Transmittal 126 (5-21-10)
• For more than 1 indication simultaneously, patient
is eligible for one course
• Similar to stable angina diagnosis-medical
necessity documentation would be included in
patient chart for “new” indication/event
Appropriate Referrals or Not
To be discussed by panel:
• LVADs?
– Destination therapy
• Re-hospitalization during CR course?
– HF dx
– Non-cardiac dx
• Chronic milrinone infusion?