I. Related Policies

PARTNERSHIP HEALTHPLAN OF CALIFORNIA POLICY/ PROCEDURE

Policy/Procedure Number: MCUP3111 (Previously MPUP3111) Lead Department: Health Services ☒External Policy Policy/Procedure Title: Pulmonary Rehabilitation ☐ Internal Policy Original Date: 10/20/2010 Next Review Date: 02/15/2018 Last Review Date: 02/15/2017 Applies to: ☒ Medi-Cal ☐ Employees Reviewing ☒ IQI ☐ P & T ☒ QUAC Entities: ☐ OPERATIONS ☐ EXECUTIVE ☐ COMPLIANCE ☐ DEPARTMENT

Approving ☐ BOARD ☐ COMPLIANCE ☐ FINANCE ☒ PAC Entities: ☐ CEO ☐ COO ☐ CREDENTIALING ☐ DEPT. DIRECTOR/OFFICER Approval Signature: Robert Moore, MD, MPH Approval Date: 02/15/2017

I. RELATED POLICIES: MCUP3041 - TAR Review Process

II. IMPACTED DEPTS: A. Health Services B. Claims C. Member Services

III. DEFINITIONS: N/A

IV. ATTACHMENTS: A. Pulmonary Rehabilitation Questionnaire

V. PURPOSE: To offer pulmonary rehabilitation as an enhanced Partnership HealthPlan of California (PHC) benefit for those members who meet the policy criteria.

VI. POLICY / PROCEDURE: A. Pulmonary rehabilitation is defined as an evidence-based, multidisciplinary, and comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activities. The primary goal of pulmonary rehabilitation is to restore the patient to the highest level of independent function by helping patients become more physically active, learn more about their disease, treatment options, and how to cope. B. All pulmonary rehabilitation requires prior authorization. The provider must submit the treatment authorization request (TAR) for consideration. C. The following codes may be used when applicable for TAR and claim submission: C.1. G0237 – Pulmonary Therapeutic Procedure to Build Strength and Endurance C.2. G0238 – Pulmonary Rehab 1:1 C.3. G0239 – Pulmonary Rehab Group Training C.4. G0424 – Pulmonary Rehab Programs C.5. 93041 – ECG Monitoring

of 4 Policy/Procedure Number: MCUP3111 (Previously MPUP3111) Lead Department: Health Services Policy/Procedure Title: Pulmonary Rehabilitation ☒ External Policy ☐ Internal Policy Original Date: 10/20/2010

Next Review Date: 02/15/2018 Last Review Date: 02/15/2017 Applies to: ☒ Medi-Cal ☐ Employees

D. Members eligible for this benefit must meet the following criteria, and a completed Pulmonary Rehabilitation Questionnaire must be submitted with the TAR. D.1. Chronic Obstructive Pulmonary Disease (COPD) D.1.a. Severe, at least stage II COPD, by FEV1 of less than 60% of predicted value and DLCO of less than 60% of predicted. Pulmonary Function Testing (PFT) results must be submitted with TAR. D.1.b. Decreased quality of life due to problems with control of COPD D.1.c. Worsening pulmonary symptoms D.1.d. Maximized pharmaceutical treatment D.1.e. No longer smoking cigarettes or at least actively quitting by evidence of use of tobacco cessation product D.2. Interstitial lung disease (ILD) or idiopathic pulmonary fibrosis (IPF) D.2.a. Dx of ILD or Idiopathic pulmonary fibrosis D.2.b. FEV1/FVC >70% of predicted D.2.c. TLC <60% of predicted D.2.d. Decreased quality of life due to problems with control of COPD D.2.e. Worsening pulmonary symptoms D.2.f. Maximized pharmaceutical treatment D.2.g. DLCO of less than 60% of predicted E. Members who meet the criteria will initially be approved up to a maximum of 24 visits. Additional visits can be requested with evidence of compliance combined with improvements and benefits of pulmonary rehabilitation.

VII. REFERENCES: A. 2007 Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines for Pulmonary Rehabilitation, Effects of Pulmonary Rehabilitation in Patients with Restrictive Lung Diseases, Salhi,B et.al. CHEST /137/2/February, 2010 B. Benefit approved by Board Resolution number 10.5, dated January 26, 2011

VIII. DISTRIBUTION: A. Provider Manual B. PHC Directors

IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Senior Director, Health Services

X. REVISION DATES: Medi-Cal 03/21/12; 02/18/15; 02/17/16; 02/15/17

PREVIOUSLY APPLIED TO:

Next Review Date: 02/15/2018 Last Review Date: 02/15/2017 Applies to: ☒ Medi-Cal ☐ Employees PartnershipAdvantage: MPUP3111 - 10/20/2010 to 01/01/2015

Next Review Date: 02/15/2018 Last Review Date: 02/15/2017 Applies to: ☒ Medi-Cal ☐ Employees

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In accordance with the California Health and Safety Code, Section 1363.5, this policy was developed with involvement from actively practicing health care providers and meets these provisions:

 Consistent with sound clinical principles and processes  Evaluated and updated at least annually  If used as the basis of a decision to modify, delay or deny services in a specific case, the criteria will be disclosed to the provider and/or enrollee upon request

The materials provided are guidelines used by PHC to authorize, modify or deny services for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under PHC.