TL;DR: Aetna, a CVS Health company, modified CPB 0021 governing outpatient cardiac rehabilitation coverage, effective December 4, 2025. Billing teams need to verify eligibility criteria, session limits, and diagnosis code alignment before submitting claims on CPT 93797, 93798, and HCPCS G0422, G0423.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna, a CVS Health company |
| Policy | Cardiac Rehabilitation — CPB 0021 |
| Policy Code | CPB 0021 |
| Change Type | Modified |
| Effective Date | December 4, 2025 |
| Impact Level | High |
| Specialties Affected | Cardiology, Cardiac Rehabilitation, Cardiovascular Surgery, Physical Medicine |
| Key Action | Audit your Phase II cardiac rehab claims for qualifying diagnosis, session count, and physician prescription documentation before billing CPT 93797 or 93798 |
Aetna Cardiac Rehabilitation Coverage Criteria and Medical Necessity Requirements 2025
The Aetna cardiac rehabilitation coverage policy under CPB 0021 covers outpatient Phase II programs only. Phase III and Phase IV are not covered — and Aetna is explicit about that. If your facility runs maintenance-phase programs and you've been billing S9472 for those, stop. That code is excluded for Phase III and Phase IV under this policy.
Medical necessity requires two things to be true at the same time: the member must have a qualifying diagnosis, and the program must meet specific structural requirements. Both gates must be open. One without the other is a claim denial waiting to happen.
Qualifying Diagnoses for Medical Necessity
Aetna covers Phase II cardiac rehab when a physician individually prescribes it within 12 months of any of these documented diagnoses:
| # | Covered Indication |
|---|---|
| 1 | Acute myocardial infarction within the preceding 12 months |
| 2 | Major open heart surgery — including CABG, great vessel surgery, heart transplantation or heart-lung transplantation, major pulmonary surgery, open MAZE arrhythmia surgery, ventricular assist device placement, atrial myxoma removal, surgical septal myectomy via thoracotomy, thoracic aortic aneurysm repair, or transcatheter valve replacement or repair |
| 3 | Chronic stable angina pectoris unresponsive to medical therapy that prevents the member from meeting domestic or occupational needs — especially where modifiable coronary risk factors or poor exercise tolerance are present |
| 4 | Percutaneous coronary intervention — including PTCA, atherectomy, and stenting |
| 5 | Sustained ventricular tachycardia or fibrillation, or survival of sudden cardiac death |
| 6 | Stable CHF with LVEF of 35% or less and NYHA class II–IV symptoms, despite optimal heart failure therapy for at least six weeks — where "stable" means no major cardiovascular hospitalization or procedure in the past six weeks and none planned within six months |
The CHF criterion is the one most likely to generate denials. Document the LVEF, the NYHA class, and the duration of optimal therapy explicitly in the medical record. Aetna will look for all three.
Program Requirements That Must Be Met
Qualifying diagnosis alone doesn't get you reimbursement. The program itself must meet every one of these criteria:
| # | Covered Indication |
|---|---|
| 1 | Physician-prescribed exercise on each day services are furnished |
| 2 | Maximum of two 1-hour sessions per day, up to 36 sessions over 36 weeks (typically two to three sessions per week for 12 to 18 weeks) |
| 3 | Direct supervision by a physician, NP, or PA — they don't have to be in the room, but must be immediately available at all times |
| 4 | Facility in a physician's office or outpatient hospital setting with emergency and cardiopulmonary equipment on-site |
| 5 | An individualized outpatient exercise program the patient can self-monitor |
| 6 | Psychosocial assessment completed |
| 7 | Cardiac risk factor modification through education, counseling, and behavioral intervention |
| 8 | Outcomes assessment using objective clinical measures of exercise performance |
If your program lacks any of these — especially the psychosocial assessment or the outcomes measurement — document it before billing. Missing documentation is the fastest path to a claim denial under this coverage policy.
Additional Qualifying Events
Members can get additional cardiac rehab sessions if they have another qualifying event. Aetna covers a new course for another cardiovascular surgery or PCI, another documented MI, or extension of a qualifying condition. Each new course still has to meet all the same program requirements. The 36-session limit resets — it doesn't stack.
Aetna Cardiac Rehabilitation Exclusions and Non-Covered Indications
Two CPT codes are explicitly not covered for the indications listed in CPB 0021: CPT 92997 (percutaneous transluminal pulmonary artery balloon angioplasty, single vessel) and CPT 92998 (each additional vessel). These are pulmonary artery procedures — not standard coronary interventions — and Aetna does not consider them qualifying events for cardiac rehabilitation under this policy.
Phase III and Phase IV maintenance programs are also not covered. This applies to CPT 93798 and S9472 specifically. Both codes are flagged as not covered for those phases. If your program transitions patients into a maintenance phase and you bill Aetna, expect denials.
Weight management (S9449), exercise classes (S9451), nutrition classes (S9452), smoking cessation classes (S9453), stress management classes (S9454), and nutritional counseling visits (S9470) are listed as related codes — not covered cardiac rehab services. They're part of the broader care picture, but Aetna won't pay for them under CPB 0021.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Acute MI within preceding 12 months | Covered | 93797, 93798, G0422, G0423, S9472 | Physician prescription required within 12-month window |
| Major open heart surgery (CABG, transplant, TAVR, VAD, etc.) | Covered | 93797, 93798, G0422, G0423, S9472 | Includes transcatheter valve repair/replacement |
| Chronic stable angina unresponsive to medical therapy | Covered | 93797, 93798, G0422, G0423 | Must show functional limitation; modifiable risk factors or poor exercise tolerance required |
| Percutaneous coronary intervention (PTCA, atherectomy, stenting) | Covered | 93797, 93798, G0422, G0423 | Standard PCI indications only |
| Sustained ventricular tachycardia/fibrillation or sudden cardiac death survival | Covered | 93797, 93798, G0422, G0423 | Documentation of event required |
| Stable CHF with LVEF ≤35%, NYHA class II–IV on optimal therapy ≥6 weeks | Covered | 93797, 93798, G0422, G0423 | "Stable" defined as no major CV event in past 6 weeks and none planned within 6 months |
| Phase III or Phase IV cardiac rehabilitation (maintenance) | Not Covered | 93798, S9472 | Explicitly excluded for these phases |
| Pulmonary artery balloon angioplasty (single vessel) | Not Covered | 92997 | Not a qualifying cardiac rehab indication |
| Pulmonary artery balloon angioplasty (additional vessels) | Not Covered | 92998 | Not a qualifying cardiac rehab indication |
| Weight management, exercise, nutrition, smoking cessation, stress management classes | Not Covered Under CPB 0021 | S9449, S9451, S9452, S9453, S9454, S9470 | Related to care but not reimbursable as cardiac rehab |
Aetna Cardiac Rehabilitation Billing Guidelines and Action Items 2025
| # | Action Item |
|---|---|
| 1 | Verify the qualifying diagnosis before billing CPT 93797 or 93798. The diagnosis must be one of the six listed indications. Map it to the correct ICD-10-CM code from the policy's 187-code list. A mismatch between the CPT and the diagnosis code is a direct path to denial. |
| 2 | Confirm the physician prescription is on file and dated within 12 months of the qualifying event. Aetna requires individual physician prescription for every course of treatment. If the prescription is missing or undated, hold the claim until it's corrected. |
| 3 | Document CHF cases to the full clinical standard before billing. For CHF patients, your records must show LVEF of 35% or less, NYHA class II–IV classification, and at least six weeks on optimal heart failure therapy. Document that the patient has been stable — no major cardiovascular hospitalization in the past six weeks, none planned in the next six months. |
| 4 | Stop billing S9472, CPT 93798, or any covered code for Phase III or Phase IV programs. These are explicitly excluded. If your program has patients transitioning from Phase II to maintenance, flag those encounters in your charge capture system so they don't go out under CPB 0021 codes. |
| 5 | Audit your session counts before the 36-session limit is hit. The policy allows up to 36 sessions over 36 weeks. If a member needs more, document a new qualifying event. Without a new qualifying diagnosis, sessions beyond 36 won't get reimbursement. |
| 6 | Check prior authorization requirements for your specific Aetna plan type. CPB 0021 sets the coverage policy framework, but individual plan documents may layer on prior authorization requirements. Check the member's specific plan before the first session, not after. If you're not sure whether prior auth applies to your plan mix, call Aetna provider services or ask your compliance officer before December 4, 2025. |
| 7 | Ensure your facility and supervision documentation is clean. The policy requires that a physician, NP, or PA be immediately available during every session. Document who was on-site and available — not just who prescribed the program. Aetna can and does audit this. |
| 8 | Update your charge capture to flag CPT 92997 and 92998 as non-covered. If your billing team is coding PCI-related procedures and someone mistakenly includes pulmonary artery balloon angioplasty codes, those claims will deny under this policy. Add a hard stop in your charge capture workflow for these codes in cardiac rehab contexts. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for Cardiac Rehabilitation Under CPB 0021
Covered CPT Codes (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| 93797 | CPT | Physician or other qualified health care professional services for outpatient cardiac rehabilitation |
| 93798 | CPT | Physician or other qualified health care professional services for outpatient cardiac rehabilitation with continuous ECG monitoring (per session) — not covered for Phase III or Phase IV |
Covered HCPCS Codes (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| G0422 | HCPCS | Intensive cardiac rehabilitation; with or without continuous ECG monitoring with exercise, per session |
| G0423 | HCPCS | Intensive cardiac rehabilitation; with or without continuous ECG monitoring; without exercise, per session |
| S9472 | HCPCS | Cardiac rehabilitation program, non-physician provider, per diem — not covered for Phase III or Phase IV |
Not Covered CPT Codes
| Code | Type | Description | Reason |
|---|---|---|---|
| 92997 | CPT | Percutaneous transluminal pulmonary artery balloon angioplasty; single vessel | Not a covered cardiac rehab indication under CPB 0021 |
| 92998 | CPT | Percutaneous transluminal pulmonary artery balloon angioplasty; each additional vessel | Not a covered cardiac rehab indication under CPB 0021 |
Key ICD-10-CM Diagnosis Codes (Selected — 187 Total in Policy)
| Code | Description |
|---|---|
| D15.1 | Benign neoplasm of heart (atrial myxoma) |
| I20.0 | Unstable angina |
| I20.89 | Other forms of angina pectoris (stable angina) |
| I21.01–I25.9 | Ischemic heart disease (range) |
| I21.A1 | Myocardial infarction type 2 |
| I21.A9 | Other myocardial infarction type |
| I27.24 | Chronic thromboembolic pulmonary hypertension |
| I09.81 | Rheumatic heart failure (congestive) |
| I11.0 | Hypertensive heart disease with heart failure |
| I13.0 | Hypertensive heart and chronic kidney disease with heart failure, stage 1–4 CKD |
| I13.2 | Hypertensive heart and chronic kidney disease with heart failure, stage 5 CKD |
| I30.0–I30.9 | Acute pericarditis (various types) |
| I31.1 | Chronic constrictive pericarditis (following pericardiectomy) |
| I34.0–I34.9 | Nonrheumatic mitral valve disorders |
| I35.0–I35.9 | Nonrheumatic aortic valve disorders (moderate to severe stenosis) |
| I05.0–I05.9 | Rheumatic mitral valve diseases |
| I06.0–I08.9 | Rheumatic aortic, mitral, tricuspid, and multiple valve diseases |
| I02.0 | Rheumatic chorea with heart involvement |
The full policy lists 187 ICD-10-CM codes. Review the complete list at the Aetna CPB 0021 source document before finalizing your diagnosis code mapping.
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