Aetna modified CPB 0267 for intensive cardiac rehabilitation (ICR) programs, effective September 26, 2025. Here's what billing teams need to know.
Aetna, a CVS Health company, updated its intensive cardiac rehabilitation coverage policy under CPB 0267 in the Aetna system. The policy governs HCPCS codes G0422 and G0423 — the two primary billing codes for ICR sessions. If your practice or facility bills for Ornish, Pritikin, or Benson-Henry ICR programs, this update directly affects your charge capture and prior authorization workflow.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna, a CVS Health company |
| Policy | Intensive Cardiac Rehabilitation Programs |
| Policy Code | CPB 0267 |
| Change Type | Modified |
| Effective Date | September 26, 2025 |
| Impact Level | Medium |
| Specialties Affected | Cardiology, Cardiac Rehabilitation, Preventive Medicine, Nutrition/Dietetics, Behavioral Health |
| Key Action | Confirm patients meet CPB 0021 medical necessity criteria before billing G0422 or G0423 for ICR sessions |
Aetna Intensive Cardiac Rehabilitation Coverage Criteria and Medical Necessity Requirements 2025
Aetna considers ICR programs medically necessary when a patient meets the criteria for standard cardiac rehabilitation outlined in CPB 0021. That's the governing document for cardiac rehab medical necessity. If a patient doesn't qualify for Phase II cardiac rehab under CPB 0021, they don't qualify for ICR under CPB 0267. There's no separate eligibility path.
The three recognized ICR programs are specific: the Benson-Henry Institute Cardiac Wellness Program, the Ornish cardiac treatment program, and the Pritikin Program. Aetna treats ICR as an alternative to traditional Phase II cardiac rehab — not a supplement to it. You're billing one or the other, not both.
Session limits are strict and non-negotiable for reimbursement purposes. ICR is limited to 72 one-hour sessions total, up to six sessions per day, over a maximum of 18 weeks. If your facility is scheduling patients beyond those thresholds, you're creating claim denial exposure. Lock those limits into your scheduling system now.
The primary billing codes for covered ICR are:
| # | Covered Indication |
|---|---|
| 1 | G0422 — Intensive cardiac rehabilitation with or without continuous ECG monitoring, with exercise, per session |
| 2 | G0423 — Intensive cardiac rehabilitation with or without continuous ECG monitoring, without exercise, per session |
Both codes are covered when selection criteria are met. Bill G0422 when exercise is included in the session. Bill G0423 when it isn't. The distinction matters — don't default to one code for all sessions.
On prior authorization: the policy doesn't explicitly state a prior auth requirement, but ICR programs are a specialty service with specific eligibility criteria tied to another policy (CPB 0021). Check Aetna's prior authorization requirements for your plan types before scheduling the first session. Assuming prior auth isn't needed and being wrong will cost you far more than the call to verify.
Aetna Intensive Cardiac Rehabilitation Exclusions and Non-Covered Indications
The policy draws a clear line at HCPCS codes S0340, S0341, and S0342. These codes represent lifestyle modification programs for coronary artery disease management — programs that may look similar to ICR on the surface but don't meet Aetna's coverage criteria under CPB 0267. Aetna explicitly lists these as not covered for the indications in this policy.
If your program has been billing under S0340–S0342 expecting coverage, that's a problem to fix immediately. These codes will deny. Document why your program qualifies as a recognized ICR program under G0422 or G0423 instead.
The virtual delivery provision is also effectively closed. Aetna aligned with Medicare policy to cover ICR delivered virtually, but only through the later of December 31, 2021, or the end of the calendar year the public health emergency ended. That window has passed. Virtual ICR delivery doesn't have a separate coverage pathway under this policy anymore.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| ICR for patients meeting CPB 0021 cardiac rehab criteria | Covered | G0422, G0423 | Max 72 sessions, up to 6/day, over 18 weeks |
| Ornish Program | Covered | G0422, G0423 | Must meet CPB 0021 criteria |
| Pritikin Program | Covered | G0422, G0423 | Must meet CPB 0021 criteria |
| Benson-Henry Institute Cardiac Wellness Program | Covered | G0422, G0423 | Must meet CPB 0021 criteria |
| Lifestyle modification programs for CAD (non-ICR) | Not Covered | S0340, S0341, S0342 | Explicitly excluded under CPB 0267 |
| Virtual ICR delivery | Not Covered (PHE period ended) | G0422, G0423 | Coverage ended with the PHE |
| ICR sessions beyond 72 total | Not Covered | G0422, G0423 | Hard session cap — no exceptions noted |
Aetna Intensive Cardiac Rehabilitation Billing Guidelines and Action Items 2025
| # | Action Item |
|---|---|
| 1 | Cross-reference CPB 0021 before billing. Every ICR patient must meet the medical necessity criteria in CPB 0021 — Cardiac Rehabilitation: Outpatient. Pull that policy and confirm your patient documentation supports eligibility before September 26, 2025. If you're not already documenting against CPB 0021 criteria, start now. |
| 2 | Audit your charge capture for G0422 vs. G0423. These codes are not interchangeable. G0422 is for sessions that include exercise. G0423 is for sessions without exercise. Review your session notes to confirm you're mapping the right code to the right session type. A blanket charge template that always fires G0422 will generate inaccurate claims. |
| 3 | Hard-code the 72-session limit in your scheduling and billing system. The policy caps ICR at 72 one-hour sessions. Set a hard stop in your EHR or billing platform so no patient crosses that threshold without a manual review. Claims for session 73 and beyond will deny, and appeals will be difficult without a policy basis. |
| 4 | Stop billing S0340, S0341, and S0342 for Aetna patients in ICR programs. These codes are explicitly not covered under CPB 0267. If your team has been using these codes for lifestyle modification programs bundled with cardiac care, audit your Aetna claims going back 12 months. Identify any that should have been billed under G0422 or G0423, and evaluate whether corrected claims or refunds are warranted. If you're unsure how to handle the audit, talk to your compliance officer before the effective date. |
| 5 | Verify prior authorization requirements at the plan level. CPB 0267 doesn't spell out a blanket prior auth requirement, but that doesn't mean prior auth isn't needed. Aetna's prior authorization requirements vary by plan type and product. For commercial, Medicare Advantage, and exchange plans, verify separately. One phone call or portal check before a patient starts an 18-week program is far cheaper than a retrospective denial. |
| 6 | Remove virtual delivery from your ICR workflow for Aetna. The temporary COVID-era coverage for virtual ICR is over. If your program still offers a virtual track and you're billing Aetna for it under G0422 or G0423, those claims will not be covered. Update your intake process to reflect in-person-only delivery for Aetna patients. |
| 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 Intensive Cardiac Rehabilitation Under CPB 0267
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 |
Not Covered HCPCS Codes
| Code | Type | Description | Reason |
|---|---|---|---|
| S0340 | HCPCS | Lifestyle modification program for management of coronary artery disease, including all supportive services | Not covered for indications listed in CPB 0267 |
| S0341 | HCPCS | Lifestyle modification program for management of coronary artery disease, including all supportive services | Not covered for indications listed in CPB 0267 |
| S0342 | HCPCS | Lifestyle modification program for management of coronary artery disease, including all supportive services | Not covered for indications listed in CPB 0267 |
Other CPT Codes Related to CPB 0267
These codes are associated with services that often appear alongside ICR — psychotherapy, medical nutrition therapy, preventive medicine, and counseling. They aren't covered or excluded under CPB 0267 specifically, but your billing team should understand the full scope of services tied to ICR programs.
| Code | Type | Description |
|---|---|---|
| 90785 | CPT | Interactive complexity (add-on code) |
| 90832 | CPT | Psychotherapy |
| 90833 | CPT | Psychotherapy |
| 90834 | CPT | Psychotherapy |
| 90835 | CPT | Psychotherapy |
| 90836 | CPT | Psychotherapy |
| 90837 | CPT | Psychotherapy |
| 90838 | CPT | Psychotherapy |
| 90839 | CPT | Psychotherapy |
| 90840 | CPT | Psychotherapy |
| 97802 | CPT | Medical nutrition therapy |
| 97803 | CPT | Medical nutrition therapy |
| 97804 | CPT | Medical nutrition therapy |
| 99381–99390 | CPT | Preventive medicine services (new patient) |
| 99391–99397 | CPT | Preventive medicine services (established patient) |
| 99401 | CPT | Preventive medicine, individual counseling |
| 99402 | CPT | Preventive medicine, individual counseling |
| 99403 | CPT | Preventive medicine, individual counseling |
| 99404 | CPT | Preventive medicine, individual counseling |
| 99406 | CPT | Smoking and tobacco use cessation counseling |
| 99407 | CPT | Smoking and tobacco use cessation counseling |
| 99411 | CPT | Preventive medicine, group counseling |
| 99412 | CPT | Preventive medicine, group counseling |
Other HCPCS Codes Related to CPB 0267
| Code | Type | Description |
|---|---|---|
| G0270 | HCPCS | Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year |
| G0271 | HCPCS | Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year |
| S9449 | HCPCS | Weight management classes, non-physician provider, per session |
| S9451 | HCPCS | Exercise classes, non-physician provider, per session |
| S9452 | HCPCS | Nutrition classes, non-physician provider, per session |
| S9453 | HCPCS | Smoking cessation classes, non-physician provider, per session |
| S9454 | HCPCS | Stress management classes, non-physician provider, per session |
| S9470 | HCPCS | Nutritional counseling, dietitian visit |
Key ICD-10-CM Diagnosis Codes
The policy lists 183 ICD-10-CM codes. Below are the primary diagnostic categories represented. Your billing team should confirm the full code set against Aetna's source document.
| Code | Description |
|---|---|
| C61 | Malignant neoplasm of prostate |
| E08.00–E13.9 | Diabetes mellitus (all types and manifestations) |
| E78.0–E78.6 | Disorders of lipoprotein metabolism and other lipidemias |
| E88.810–E88.819 | Metabolic syndrome |
| F17.200–F17.209 | Nicotine dependence |
The remaining 133 ICD-10-CM codes span cardiovascular diagnoses, additional metabolic conditions, and comorbidities relevant to cardiac rehab eligibility. Cross-reference the full code list in the source policy at Aetna's CPB 0267 document to confirm coverage for your specific patient population. Don't rely on a partial code list when building your charge capture rules.
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