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. Outline • New Medicare coverage regulation • Clinical interpretation of CMS eligibility criteria • FAQs & Clinical vignettes Who is This “New” Patient Population? • 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 procedures.” NCD 20.10.1 What Does That Mean? Stable • 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 appropriateness. FAQs 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? – BTT – Destination therapy • Re-hospitalization during CR course? – HF dx – Non-cardiac dx • Chronic milrinone infusion?
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