Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) — NCD 371 | CMS Coverage Update

CMS modified NCD 371 governing supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD), with the policy update recorded January 9, 2026. Here's what billing teams need to know.

The Centers for Medicare & Medicaid Services reviewed and republished NCD 371, the National Coverage Determination governing Medicare coverage of SET for beneficiaries with intermittent claudication (IC) due to PAD. The policy covers up to 36 sessions over 12 weeks, with MAC-level discretion to authorize an additional 36 sessions beyond the national floor. No specific CPT or HCPCS codes are listed in the current policy document — more on what that means for your billing below.

Quick-Reference Table

CMS Supervised Exercise Therapy Coverage Criteria and Medical Necessity Requirements 2026

The CMS SET coverage policy under NCD 371 Medicare has been in place since May 25, 2017, but this 2026 update confirms the criteria remain active and enforceable. If your billing team is submitting claims for SET without double-checking these requirements, you are exposed to claim denial.

Medical necessity under this policy requires that the patient has a confirmed diagnosis of symptomatic PAD with intermittent claudication. That's the clinical threshold. No claudication, no coverage — full stop.

Beyond the diagnosis, the SET program itself must meet four structural requirements. All four must be satisfied for a claim to hold up to audit. Think of them as a checklist your compliance officer should be able to walk through on any SET claim:

1. Session structure. Each session must last 30 to 60 minutes. The content must be a therapeutic exercise-training program specifically for PAD patients with claudication — not general cardiac rehab, not general physical therapy.

2. Facility setting. The program must take place in a hospital outpatient setting or a physician's office. Home exercise programs do not qualify under this coverage policy, no matter how well-structured. This distinction matters for reimbursement — setting drives the billing pathway entirely.

3. Qualified personnel. Sessions must be delivered by qualified auxiliary personnel trained in exercise therapy for PAD. "Trained" is the operative word here. Your documentation needs to show that the staff member delivering the session has the right background. Generic PT credentials alone may not be enough if your MAC scrutinizes personnel qualifications.

4. Direct supervision. A physician (as defined in Section 1861(r)(1)), physician assistant, or nurse practitioner/clinical nurse specialist (as identified in Section 1861(aa)(5)) must be present and directly supervising. That supervisor must also be trained in both basic and advanced life support. This isn't on-call or general oversight — it's direct supervision, which has a specific Medicare definition your billing team should know cold.

There is no prior authorization requirement stated at the national level under NCD 371. However, the referral process functions as a gatekeeping mechanism. Before a beneficiary can start SET, they need a face-to-face visit with the physician responsible for their PAD treatment. At that visit, the physician must provide information on cardiovascular disease and PAD risk factor reduction — education, counseling, behavioral interventions, or outcome assessments. That visit and its content must be documented. Missing documentation on the referral visit is a fast path to claim denial.

The billing guidelines for SET also require a second referral for any sessions beyond the initial 36. If your facility plans to bill for extended sessions — which your Medicare Administrative Contractor may allow at their discretion — you need that second referral in the chart before you submit.

CMS Supervised Exercise Therapy Exclusions and Non-Covered Indications

This is clean and clear: SET is non-covered for any beneficiary with absolute contraindications to exercise. That determination rests with the primary physician.

The policy doesn't enumerate which contraindications qualify. That's intentional — the physician's clinical judgment is the gatekeeping mechanism. But the implication for billing is important. If a patient has a documented absolute contraindication and your team submits a SET claim, that's not a gray area. That's a coverage policy violation, and it will deny.

The broader exclusions worth tracking are structural, not clinical:

None of these are new. But they're worth restating because they're also the most common reasons SET claims get denied on audit.

Coverage Indications at a Glance

CMS Supervised Exercise Therapy Billing Guidelines and Action Items 2026

The effective date of January 9, 2026 means these standards are active now. Here's what to do:

1. Audit your SET program structure against all four criteria.
Pull your current SET protocol and check it against the four requirements — session duration, setting, personnel qualifications, and direct supervision with life support training. If any component doesn't meet the standard, fix it before billing, not after a denial.

2. Confirm your MAC's policy on extended sessions.
NCD 371 covers 36 sessions nationally. Your Medicare Administrative Contractor has the discretion to cover an additional 36 sessions, but that coverage is not guaranteed. Contact your MAC or check their local coverage determination (LCD) supplements to know exactly what they allow in your jurisdiction before promising patients — or billing for — sessions 37 through 72.

3. Build a referral checklist into your intake workflow.
The face-to-face referral visit is a medical necessity requirement, not optional documentation. Build a checklist that confirms the visit occurred, the physician addressed cardiovascular disease and PAD risk factor reduction, and a second referral is in the chart before extended sessions begin. Missing this documentation is the top reason SET claims get flagged.

4. Verify personnel credentials before billing.
Your auxiliary staff delivering SET sessions must be trained in exercise therapy for PAD specifically. Don't assume general physical therapy credentials satisfy this. Document each staff member's qualifications in your records. If a MAC audits a claim, they will ask.

5. Confirm your direct supervision documentation.
Supervised exercise therapy billing lives or dies on the direct supervision requirement. Whoever is supervising must be a physician, PA, or NP/CNS — and must have life support training. Document who supervised each session and confirm their credentials are current. An undocumented supervisor is as bad as no supervisor in a claims audit.

6. Check your billing pathway for the correct setting modifier.
NCD 371 covers SET in two settings: hospital outpatient and physician's office. The place of service code on your claim must match where the service was actually delivered. A mismatch here is an easy denial and an easy fix — catch it in charge capture, not in remittance.

If your SET program is new, or if your organization recently transitioned the service to a different setting, loop in your compliance officer before submitting claims. The intersection of supervision requirements, setting requirements, and MAC-level discretion on extended sessions creates real exposure if your documentation doesn't line up perfectly.

CPT, HCPCS, and ICD-10 Codes for Supervised Exercise Therapy Under NCD 371

Covered CPT and HCPCS Codes

The NCD 371 policy document does not list specific CPT or HCPCS codes. This is a known gap with this NCD. CMS issued claims processing instructions through transmittals TN 3969, TN 3992, TN 4016, and TN 4049 when the policy was originally established in 2017 — those transmittals contain the actual billing codes your team should be using.

Check those transmittals directly at CMS.gov, or confirm the current applicable codes with your MAC's provider education team. Do not bill SET claims without verifying the correct codes through those transmittals. Using the wrong code — even for a covered service — will result in denial.

Key ICD-10-CM Diagnosis Codes

The policy does not specify ICD-10 codes. For PAD with intermittent claudication, work with your coding team to identify the appropriate codes from the I70 category (Atherosclerosis). Your MAC may have LCD-level guidance that specifies covered diagnosis codes for SET — check that before submitting.