CMS Supervised Exercise Therapy (SET) for PAD: What Billing Teams Need to Know About NCD 371

CMS has modified its National Coverage Determination for Supervised Exercise Therapy (SET) for symptomatic Peripheral Artery Disease (PAD) under NCD 371, with an updated effective date of March 12, 2026. If your practice or hospital outpatient department treats Medicare patients with intermittent claudication, this policy directly affects how you document, refer, and bill for SET services. Here's what changed and what your revenue cycle team needs to do now.

What CMS Covers Under NCD 371: SET for Peripheral Artery Disease

The Centers for Medicare & Medicaid Services has determined that evidence is sufficient to cover Supervised Exercise Therapy for Medicare beneficiaries with intermittent claudication (IC) as a treatment for symptomatic PAD. This coverage has been in effect for services performed on or after May 25, 2017, and NCD 371 remains the governing national policy.

CMS's rationale is grounded in clinical evidence: SET has been shown to be significantly more effective than unsupervised exercise for IC, and performs at least as well as more invasive revascularization procedures that Medicare already covers. It's also considered a minimally invasive intervention that may slow PAD progression and reduce cardiovascular event risk—a meaningful consideration for a population that typically carries substantial comorbidity burden.

The core coverage allowance is up to 36 sessions over a 12-week period, subject to strict program requirements.

Medical Necessity Criteria: All Four Requirements Must Be Met

This is where denials happen. CMS does not cover SET broadly—it covers SET within a program that meets all of the following structural components simultaneously. Your SET program must:

All four criteria must be met for every covered session. A gap in any one of them creates a medical necessity vulnerability on audit.

The Face-to-Face Referral Requirement: Non-Negotiable

Before a beneficiary can begin a covered SET program, they must have a face-to-face visit with the physician responsible for their PAD treatment to obtain the SET referral. This is not a formality—it's a coverage requirement.

At that visit, the beneficiary must receive information regarding cardiovascular disease and PAD risk factor reduction. CMS specifies that this can include education, counseling, behavioral interventions, and outcome assessments. Your documentation for this visit needs to reflect that these elements were provided, not just that the referral was written.

Missing or inadequate documentation of this visit is one of the most common reasons SET claims are denied or recouped on audit. Make sure the referring physician's note explicitly reflects the PAD risk factor education provided.

Extended Coverage: MAC Discretion Beyond 36 Sessions

The national coverage determination sets a floor, not a ceiling—at least in certain cases. Medicare Administrative Contractors (MACs) have the discretion to cover an additional 36 sessions beyond the nationally covered 36, for a potential total of 72 sessions. This extended coverage applies over an extended time period beyond the initial 12 weeks.

Critically, a second referral is required before billing for those additional sessions. That second referral must be obtained before the extended sessions begin—billing additional sessions against only the original referral is a compliance risk.

Check with your MAC directly to confirm whether they have exercised this discretion, what documentation they require, and whether any local coverage articles govern the additional sessions. MAC-level policies vary, and you cannot assume discretionary coverage applies in your jurisdiction without verification.

Non-Covered Indications Under NCD 371

CMS is explicit: SET is nationally non-covered for beneficiaries with absolute contraindications to exercise, as determined by their primary physician. This determination must be documented in the medical record.

If a patient presents with a contraindication and you provide SET services anyway, those claims will not be covered under Medicare—and billing them creates compliance exposure. The primary physician's role in screening patients for contraindications before referral is a key checkpoint in your workflow.

Affected Codes

This policy does not list specific CPT or HCPCS codes within the NCD 371 policy document. For the applicable billing codes for SET services, consult the CMS Claims Processing Transmittals associated with this NCD—specifically Transmittals 3969, 3992, 4016, and 4049—which contain the operative claims processing instructions. Your MAC's website and billing guides are also authoritative sources for the correct codes in your jurisdiction.

What Your Billing Team Should Do