Key facts for NCD 20.10.1
- Benefit category
- Cardiac Rehabilitation Programs
- Effective date
- 02/18/2014
- Implemented 08/18/2014
- Transmittal
- Transmittal 171
- Versions published
- 1
- Manual chapter
- 20
- NCD Manual (Pub. 100-03)
TL;DR
NCD 20.10.1 sets Medicare's national policy for cardiac rehabilitation programs for chronic heart failure under the benefit category "Cardiac Rehabilitation Programs", effective 02/18/2014 and implemented 08/18/2014. Effective for dates of service on and after February 18, 2014, CMS has determined that the evidence is sufficient to expand coverage for cardiac rehabilitation services under 42 CFR §410.49(b)(1)(vii) to beneficiaries with stable, chronic heart failure,… It has been revised once since publication and binds every Medicare Administrative Contractor nationally.
Item or service described
A. General
As per sections 1861(s)(2)(CC) and 1861(eee)(1) of the Social Security Act, items and services furnished under a Cardiac Rehabilitation (CR) program may be covered under Medicare Part B. Among other things, Medicare regulations at 42CFR410.49 define key terms, address the components of a CR program, establish the standards for physician supervision, and limit the maximum number of program sessions that may be furnished. The regulations also describe the cardiac conditions that would enable a beneficiary to obtain CR services.
Effective for dates of service on and after January 1, 2010, coverage is permitted for beneficiaries who have experienced one or more of the following:
• Acute myocardial infarction within the preceding 12 months
• Coronary artery bypasses 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 Centers for Medicare & Medicaid Services (CMS) may add “other cardiac conditions as specified through a national coverage determination” (See 42 CFR §410.49(b)(1)(vii)).
Indications and limitations of coverage
B. Nationally Covered Indications
Effective for dates of service on and after February 18, 2014, CMS has determined that the evidence is sufficient to expand coverage for cardiac rehabilitation services under 42 CFR §410.49(b)(1)(vii) to beneficiaries with stable, chronic heart failure, defined as patients with left ventricular ejection fraction of 35% or less and New York Heart Association (NYHA) class II to IV symptoms despite being on optimal heart failure therapy for at least six weeks. Stable patients are defined as patients who have not had recent (≤ 6 weeks) or planned (≤ 6 months) major cardiovascular hospitalizations or procedures. (See section A above for other indications covered under 42 CFR §410.49(b)(1)(vii)).
C. Nationally Non-Covered Indications
Any cardiac indication not specifically identified in 42 CFR §410.49(b)(1)(vii) or identified as covered in this NCD or any other NCD in relation to cardiac rehabilitation services is considered non-covered.
D. Other
NA
(This NCD last reviewed February 2014.)
Text reproduced from the CMS Medicare Coverage Database record for NCD 20.10.1 version 1. View the original on cms.gov.
Revision history
07/2014 - The purpose of this Change Request (CR) is effective for dates of service on and after February 18, 2014, Medicare covers cardiac rehabilitation services to beneficiaries with stable, chronic heart failure defined as patients with left ventricular ejection fraction of 35% or less and New York Heart Association (NYHA) class II to IV symptoms despite being on optimal heart failure therapy for at least 6 weeks. Effect date: 02/18/2014. Implementation date: 08/18/2014. ( TN 171 ) (CR8758)
How this NCD shows up on remittances
A service denied under a National Coverage Determination returns CARC 50 (not deemed medically necessary) with remark N386 (decision based on an NCD); a denial citing a local policy instead carries N115. Because NCDs bind nationally, the appeal path is documentation that the patient meets the indications above, not a contractor-policy argument.
How QuickIntell applies NCD 20.10.1
QuickAuth checks the ordered service and diagnosis against NCD and LCD criteria before the encounter, QuickCode validates the diagnosis pairing on the claim, and QuickRCM routes CARC 50 denials with the policy text and the covered-code list attached so the appeal starts with evidence.
Frequently asked questions — NCD 20.10.1
What does NCD 20.10.1 cover?
Effective for dates of service on and after February 18, 2014, CMS has determined that the evidence is sufficient to expand coverage for cardiac rehabilitation services under 42 CFR §410.49(b)(1)(vii) to beneficiaries with stable, chronic heart failure, defined as patients with left ventricular ejection fraction of 35% or less and New York Heart Association (NYHA) class II to IV symptoms despite being on optimal… The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database.
When did NCD 20.10.1 take effect?
The current version (1) is effective 02/18/2014, implemented 08/18/2014, published in transmittal 171. This is the only published version.
Does a Local Coverage Determination override NCD 20.10.1?
No. A National Coverage Determination binds all Medicare Administrative Contractors; an LCD can only address services or circumstances the NCD leaves open. Claims denied under this NCD typically return CARC 50 with remark N386 (NCD) rather than N115 (LCD).
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.
- Medicare Coverage Database NCDs via the CMS Coverage APIVersion API snapshot 2026-09-27 · effective 2026-09-20 · file national-coverage-ncd.jsonSHA-256 a90fadfd264b9ef4…
Disclaimer
This page reproduces the CMS National Coverage Determination text and, for laboratory NCDs, the CMS ICD-10 edit lists, as an operational reference. Coverage decisions depend on the full policy, the claim and the contractor; nothing here is legal, clinical or billing advice. CPT codes are shown as numbers only; CPT descriptors are copyright AMA.