9.2.17.1

Prior Authorization for Cardiac Rehabilitation

Prior authorization is not required for the initial 36 sessions of cardiac rehabilitation.

Cardiac rehabilitation may be considered medically necessary beyond 36 sessions in the following circumstances:

•	The medical record must support the client has had another cardiac event; or

•	The prescribing physician documents that a continuation of cardiac rehabilitation is medically necessary. Documentation must include the following:

•	Progress made from the beginning of cardiac rehabilitation period to the current service request date, including progress towards previous goals.

•	Information that supports the client’s capability of continued measurable progress.

•	A proposed treatment plan for the requested extension dates with specific goals related to the client’s individual needs.

Requests for prior authorization for additional sessions that exceed a total of 36 sessions in 52 weeks will not be granted. Prior authorization must be obtained through the TMHP Special Medical Prior Authorization (SMPA) Department.