Cardiac Rehabilitation Programs for Chronic Heart Failure — NCD 359 | CMS Coverage Update

TL;DR: The Centers for Medicare & Medicaid Services modified NCD 359 governing cardiac rehabilitation program coverage, with a policy review date of January 9, 2026. If your team bills cardiac rehab services for Medicare patients with chronic heart failure, the medical necessity criteria in this policy directly affect your reimbursement and claim denial risk.

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Field	Detail
Payer	CMS
Policy	Cardiac Rehabilitation Programs for Chronic Heart Failure
Policy Code	NCD 359
Change Type	Modified
Effective Date	2026-01-09
Impact Level	High
Specialties Affected	Cardiology, Cardiac Rehabilitation, Internal Medicine, Heart Failure Programs
Key Action	Audit your cardiac rehab claims for heart failure patients against the LVEF ≤35% and NYHA Class II–IV criteria before submitting

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CMS Cardiac Rehabilitation Coverage Criteria and Medical Necessity Requirements 2026

NCD 359 is the National Coverage Determination governing Medicare coverage of cardiac rehabilitation programs under Medicare Part B. The Centers for Medicare & Medicaid Services published this policy update on January 9, 2026. Understanding the exact medical necessity thresholds here is the difference between clean claims and costly denials.

The baseline coverage policy under NCD 359 has been in place since January 1, 2010. It covers cardiac rehab for six standard indications: acute myocardial infarction within the preceding 12 months, coronary artery bypass surgery, current stable angina pectoris, heart valve repair or replacement, percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting, and heart or heart-lung transplant.

The harder-to-bill indication — and the one that drives the most cardiac rehab billing confusion — is chronic heart failure. CMS expanded coverage to include stable, chronic heart failure effective February 18, 2014. That coverage expansion lives under 42 CFR §410.49(b)(1)(vii), and the medical necessity criteria are tighter than most billing teams realize.

What "Stable, Chronic Heart Failure" Actually Means for Medical Necessity

CMS defines the covered heart failure population with precision. Your patient must meet all three of these criteria simultaneously:

Left ventricular ejection fraction (LVEF) of 35% or less. This is a hard threshold. A patient with an LVEF of 36% does not qualify under this NCD. The echocardiogram or imaging report documenting the LVEF needs to be in the record before you bill.

New York Heart Association (NYHA) Class II to IV symptoms. Class I patients — those with cardiac disease but no symptoms during ordinary activity — do not qualify. The physician documentation must reflect NYHA classification explicitly. If the note says "heart failure" without a functional class, that's a documentation gap that will cost you on audit.

On optimal heart failure therapy for at least six weeks. CMS requires that the patient be on guideline-directed medical therapy before cardiac rehab starts. Six weeks is the minimum. Document the therapy regimen and start date in the referral.

The stability definition adds another layer. A "stable" patient, per NCD 359, has not had a major cardiovascular hospitalization or procedure in the prior six weeks and does not have one planned within the next six months. If your patient just came out of a hospitalization three weeks ago, they don't qualify yet — even if they otherwise meet the LVEF and NYHA criteria.

This is the section where claim denial risk concentrates. Billing teams that treat heart failure as a general qualifying condition without confirming all four elements — LVEF, NYHA class, therapy duration, and stability window — are leaving themselves exposed.

Prior Authorization and Physician Supervision Requirements

NCD 359 itself does not specify prior authorization requirements at the NCD level. However, cardiac rehabilitation billing guidelines under Medicare require physician supervision of sessions, and 42 CFR §410.49 sets the supervision standards. Your cardiac rehab program must document physician oversight for each session. Missing that documentation is as damaging to a claim as missing the medical necessity criteria.

Check with your Medicare Administrative Contractor on any local coverage determination (LCD) requirements layered on top of this NCD. Some MACs have issued LCDs that add documentation or prior auth requirements for cardiac rehab services. The NCD sets the floor — your MAC may raise it.

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CMS Cardiac Rehabilitation Exclusions and Non-Covered Indications

NCD 359 is explicit about what does not qualify. Any cardiac indication not specifically listed in 42 CFR §410.49(b)(1)(vii) or identified as covered in this NCD or another related NCD is non-covered.

That's a meaningful restriction. Cardiac conditions that fall outside the six standard indications and the chronic heart failure expansion are not covered under this policy — period. CMS has left open the ability to add conditions through future NCDs, but until that happens, billing for cardiac rehab on an unlisted cardiac indication will result in denial.

The most common mistake in cardiac rehab billing: assuming that any serious cardiac diagnosis qualifies. It does not. The list is closed unless CMS opens it through a new NCD. Cardiomyopathy, arrhythmia, and other cardiac conditions that don't appear in the covered indications list are not reimbursable under NCD 359.

If your cardiologists are referring patients with conditions outside this list, you need a conversation with your medical director before those claims go out. A denied claim is recoverable. A pattern of billing non-covered indications is a compliance issue.

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Coverage Indications at a Glance

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CMS Cardiac Rehabilitation Billing Guidelines and Action Items 2026

The policy review date is January 9, 2026. Use that as your trigger to audit your cardiac rehab billing workflows now. Here are the specific steps your billing team should take.

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Cardiac Rehabilitation Under NCD 359

Covered Codes — Important Note

NCD 359 as published does not list specific CPT or HCPCS codes within the policy document. This is common for NCDs that govern program-level services — the billing codes for cardiac rehabilitation services are addressed in the associated Claims Processing Instructions rather than the NCD itself.

The relevant Claims Processing transmittal is TN 2989 (Medicare Claims Processing), available directly from CMS. Your billing team should reference that transmittal for the specific procedure codes used to bill cardiac rehabilitation sessions under Medicare Part B.

For ICD-10-CM diagnosis coding, the medical necessity criteria in section B of NCD 359 point clearly to heart failure diagnoses. Your codes need to reflect LVEF status and NYHA classification where applicable. This is a conversation for your coding team to have with your cardiologists — the clinical documentation has to support the specificity your ICD-10 codes claim.

Do not bill cardiac rehab claims without confirming the applicable codes against TN 2989 and your MAC's billing guidelines. Using the wrong procedure code is a separate denial risk from the medical necessity criteria, and it's preventable.

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