CMS Cardiac Rehabilitation Coverage for Chronic Heart Failure — NCD 359 Policy Update (2026)

CMS has issued a modification to National Coverage Determination (NCD) 359, which governs Medicare Part B coverage for Cardiac Rehabilitation (CR) programs—including the chronic heart failure (CHF) indication first established in 2014. If your practice or facility bills CR services to Medicare beneficiaries with stable CHF, this policy update is worth a close review to ensure your documentation, medical necessity criteria, and eligibility screening workflows remain aligned with current CMS requirements.

What CMS NCD 359 Covers: Cardiac Rehabilitation Program Basics

Under sections 1861(s)(2)(CC) and 1861(eee)(1) of the Social Security Act, Medicare Part B permits coverage for items and services furnished under an approved Cardiac Rehabilitation program. The regulatory framework at 42 CFR §410.49 defines program components, physician supervision standards, and session limits.

CMS has long covered CR for a defined list of cardiac conditions. Effective for dates of service on and after January 1, 2010, beneficiaries who have experienced any of the following qualify for standard CR coverage:

• 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
• A heart or heart-lung transplant

The CHF indication is separate—added through NCD authority under 42 CFR §410.49(b)(1)(vii)—and carries its own distinct eligibility criteria described in detail below.

The Chronic Heart Failure Indication: Medical Necessity Criteria Under NCD 359

Effective for dates of service on and after February 18, 2014, the Centers for Medicare & Medicaid Services determined that evidence was sufficient to extend CR coverage to beneficiaries with stable, chronic heart failure. This is not a blanket extension—CMS defined the covered population with precision, and every criterion matters for claims.

To qualify for CR services under the CHF indication, a beneficiary must meet all of the following:

1. Left Ventricular Ejection Fraction (LVEF) of 35% or less
The LVEF threshold is a hard clinical requirement. Documentation from echocardiography or another accepted imaging modality establishing LVEF ≤ 35% must be present in the medical record before CR services begin.

2. New York Heart Association (NYHA) Class II to IV Symptoms
The patient must have NYHA functional classification of II, III, or IV. Physician documentation of the NYHA classification—not just symptom description—should be explicitly stated in the referring clinician's notes.

3. Optimal Heart Failure Therapy for at Least Six Weeks
The beneficiary must have been on optimal heart failure therapy for a minimum of six weeks prior to initiating CR services. What constitutes "optimal" therapy will depend on current clinical guidelines, and the medical record must support that the treating physician considered and addressed guideline-directed medical therapy.

4. Stable Patient Status
CMS defines "stable" with specificity: the patient must not have had a major cardiovascular hospitalization or procedure within the preceding six weeks, and must not have a major cardiovascular hospitalization or procedure planned within the next six months. Both conditions apply simultaneously.

This stability definition has real claims implications. A patient who was hospitalized for decompensated heart failure five weeks ago is not eligible—even if all other criteria are met. Your referral intake process should include explicit screening for recent and planned hospitalizations.

What CMS Does Not Cover Under NCD 359

The non-coverage boundary here is straightforward but important to document correctly. Any cardiac indication that is not specifically identified in 42 CFR §410.49(b)(1)(vii) and is not otherwise covered in NCD 359 or another applicable NCD is considered non-covered under Medicare.

This means cardiac rehabilitation services furnished to beneficiaries with cardiac conditions outside the enumerated list—or CHF patients who do not meet the LVEF, NYHA, stability, and therapy duration criteria—will not be covered. Billing for non-qualifying patients creates both a claim denial risk and a potential overpayment liability.

There are no experimental or investigational designations within this NCD—coverage is either affirmatively granted under the defined criteria or non-covered by default.

Prior Authorization Requirements

NCD 359 does not establish a prior authorization requirement for cardiac rehabilitation services. However, billing teams should be aware that individual Medicare Advantage plans may impose prior authorization requirements above and beyond the NCD. If your patient population includes Medicare Advantage enrollees, verify plan-level PA requirements separately before initiating a CR program.

Affected Codes

This policy does not list specific CPT or HCPCS codes. The NCD references CR program coverage broadly under 42 CFR §410.49 and the applicable Social Security Act provisions. For claims processing guidance and applicable billing codes, CMS directs to Transmittal 2989 (Medicare Claims Processing), available at the CMS website.

Billing teams should reference the CR-specific billing codes used under their existing claims processing workflows and confirm alignment with the Transmittal 2989 instructions. No ICD-10-CM codes are specified within the NCD document itself, but diagnosis coding for CHF (including specificity of systolic vs. diastolic dysfunction and acuity) must support the documented LVEF and NYHA criteria in the medical record.

What Your Billing Team Should Do