37.86.3105 OUTPATIENT HOSPITAL SERVICES, PULMONARY REHABILITATION SERVICES
(1) Pulmonary rehabilitation services are limited to members with moderate to severe COPD, defined as GOLD classification II, III, and IV.
(2) If applicable, the patient must have ceased smoking or be in a smoking cessation class.
(3) The following pulmonary rehabilitation services are not covered:
(a) education, treatment, and therapies that are not individualized to a specific patient need or are not an integral part of the treatment session;
(b) routine psychological screening and treatment where intervention is not indicated;
(d) duplicate services;
(e) maintenance care when there is no expectation of further improvement;
(f) treatment that is not medically necessary because the patient requires a general strengthening and endurance program only; and
(g) treatment that is not medically necessary because the patient is at an early stage of pulmonary disease as demonstrated by a lack of significant findings in diagnostic testing.
History: 53-2-201, 53-6-111, MCA; IMP, 53-2-201, 53-6-101, MCA; NEW, 2006 MAR p. 1640, Eff. 6/23/06; AMD, 2006 MAR p. 2849, Eff. 11/10/06; AMD, 2014 MAR p. 1415, Eff. 7/1/14; AMD, 2016 MAR p. 829, Eff. 5/7/16.