CMS Clarifies Comprehensive Pulmonary Rehabilitation (PR) Guidelines

CMS will only cover PR services for patients diagnosed with moderate to very severe COPD (GOLD classification II, III and IV). 

In addition to the stipulation that the patients must meet GOLD classification II, III and IV, there are five specific components to any PR program that must be met and documented to insure coverage by CMS.

Physician Prescribed Exercise – CMS guidelines require that PR conditioning include both low and high intensity exercise to produce maximum clinical benefit at a minimum of twice per week.

Education and Training – CMS encourages the physician to individualize the education and training based on the patient’s medical condition and social situation. Program goals include guidance on ADL independence, understanding and adapting to personal limitations and improving other overall quality of life.

Psychosocial assessment – Documentation should support a patient’s mental and emotional status as it relates to respiratory conditioning. CMS recommends the assessment should include an evaluation of the patient’s home situation affecting the treatment parameters along with overall response and progress gained as part of the treatment plan.

Outcome Assessment Both beginning and ending assessments are required to assess overall outcome of the PR program. Clinical parameters should be measured including but not limited to the 6 minute walk, weight, exercise performance, self-reported shortness of breath, emotional well being and quality of life.

Individual Treatment Plan Each plan must be documented according to the patient’s individual diagnosis. It must be established, reviewed and signed by the PR physician every 30 days. Plans may be developed by the referring provider but officially approved and signed off from the PR physicia


Univera Healthcare will implement the federal mandate beginning August 1, 2012, on a schedule that coincides with the coverage renewal date of each employer group or direct pay member. While the renewal date of the majority of our members is January 1, 2013, some will renew at other time throughout the year. Some employer groups are exempt from the mandate due to a grandfather clause in their plan.

As there are variations in group renewal dates and group exceptions apply, it’s important that you verify member eligibility prior to delivering any preventive services included in the mandate to determine whether the service is covered in full.

Summary of Changes:

Gestational Diabetes Screening: Screening is already covered under most benefit plans; however, all laboratory services will be covered in full.

Human Papillomavirus Testing: (usually done as part of a covered Pap smear) All associated laboratory services will be covered in full.

HIV Counseling and Testing: Expands current mandate by requiring coverage of annual HIV counseling and testing for all sexually active women.

Contraceptive Methods and Counseling: Sterilization procedures, FDA–approved over the counter contraceptive methods and generic contraceptive drugs for all women with reproductive capacity will be covered in full regardless of whether a prescription drug benefit exists under the member’s policy (Note: Only generic contraceptive drugs will be covered in full. Brand name contraceptive drugs will continue to require a copay/coinsurance).

Breastfeeding Support, Supplies and Counseling:Comprehensive lactation support and counseling during pregnancy and/or postpartum, including the cost of breastfeeding equipment rental, will be covered in full for as long as the women is breast feeding.

 A complete list of preventative health services is available at To access the Preventive Services Cover Grid click on the “Providers” tab. The Women’s Health Preventative Services, which are mandated as of an employer group’s first renewal on or after August 1, 2012, have been highlighted in green. Remember, any copayments, coinsurance or deductibles called for under the members benefit plan are not applicable of any of these services.

REMINDER: Univera Community Health would like to remind you of the following summary of changes to PlusMed and Family Health Plus benefits, which became effective June 1, 2012, as defined by the NYSDOH. The information was published initially in the April 2012 issue of the New York State Medicaid Update newsletter.

Benefit Summary Medicaid Update Bulletin of Information
Knee Arthroscopy Will no longer cover knee arthroscopy using debridement and lavage, as a treatment for osteoarthritis (OA) April 2012
Growth Hormones Will no longer cover for idiopathic short stature (ISS) April 2012
Back Pain Treatment Will no longer cover prolotherapy, intradiscal steroid injections, facet joint steroid injections, systemic corticosteroids and traction (continuous or intermittent) for chronic lower back pain April 2012

All services provided are subject to medical necessity requirements. Univera Community Health will implement additional retrospective reviews, as needed, through medical necessity post-service reviews or medical necessity audit(s), in lieu of preauthorization. These audits or reviews may be conducted post-service and/or post payment.

 To access the original notice, go to: