Medical Policy Revision: Cardiac Rehabilitation in the Outpatient Setting

Effective January 1, 2018, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider certain professional claims for cardiac rehabilitation services.

Our medical policy, Cardiac Rehabilitation in the Outpatient Setting, identifies when cardiac rehabilitation services rendered in an outpatient setting are considered medically necessary or investigational.

We encourage you to review this policy in our Medical Policy Manual.

Based on the guidelines of our medical policy, Cardiac Rehabilitation in the Outpatient Setting, claims for services provided on and after January 1, 2018 will be processed as noted below.

• Based on the submitted diagnosis code(s), claims for members enrolled in Horizon BCBSNJ Medicare Advantage plans that include HCPCS codes G0422 and/or G0423 may pend while information required to determine medical appropriateness is requested and reviewed.

• Based on the submitted diagnosis code(s), HCPCS codes G0422 and/or G0423 included on claims for services provided to members enrolled in Horizon BCBSNJ Medicare Advantage plans may be denied as a service “not related” to the diagnosis code(s).

• Regardless of the submitted diagnosis code(s), HCPCS codes G0422 and/or G0423 included on claims for services provided to members enrolled in Horizon BCBSNJ plans other than Medicare Advantage plans will be denied as experimental/investigational non-covered services.

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been cancelled or postponed, the changes will be applied to claims for dates of service on and after January 1, 2018.