Key facts for NCD 20.31.1
- Benefit category
- Intensive Cardiac Rehabilitation Program
- Effective date
- 08/12/2010
- Implemented 10/25/2010
- Transmittal
- Transmittal 125
- Versions published
- 1
- Manual chapter
- 20
- NCD Manual (Pub. 100-03)
TL;DR
NCD 20.31.1 sets Medicare's national policy for the pritikin program under the benefit category "Intensive Cardiac Rehabilitation Program", effective 08/12/2010 and implemented 10/25/2010. Effective for claims with dates of service on and after August 12, 2010, the Pritikin Program meets the intensive cardiac rehabilitation (ICR) program requirements set forth by Congress in §1861(eee)(4)(A) of the Social Security Act and in regulations at 42… It has been revised once since publication and binds every Medicare Administrative Contractor nationally.
Item or service described
A. General
The Pritikin diet was designed and adopted by Nathan Pritikin in 1955. The diet was modeled after the diet of the Tarahumara Indians in Mexico, which consisted of 10% fat, 13% protein, 75-80% carbohydrates and provided 15-20 grams per day of crude fiber with only 75 mg/day of cholesterol. Over the years, the Pritikin Program (also known as the Pritikin Longevity Program) evolved into a comprehensive program that is provided in a physician’s office and incorporates a specific diet (10%-15% of calories from fat, 15%-20% from protein, 65%-75% from complex carbohydrates), exercise, and counseling lasting 21-26 days. An optional residential component is also available for participants.
Indications and limitations of coverage
B. Nationally Covered Indications
Effective for claims with dates of service on and after August 12, 2010, the Pritikin Program meets the intensive cardiac rehabilitation (ICR) program requirements set forth by Congress in §1861(eee)(4)(A) of the Social Security Act and in regulations at 42 C.F.R. §410.49(c) and, as such, has been included on the list of approved ICR programs available at http://www.cms.gov/Medicare/Medicare-General-Information/MedicareApprovedFacilitie/ .
C. Nationally Non-Covered Indications
Effective August 12, 2010, if a specific ICR program is not included on the list as a Medicare-approved ICR program, it is non-covered.
D. Other
N/A
(This NCD last reviewed August 2010.)
Text reproduced from the CMS Medicare Coverage Database record for NCD 20.31.1 version 1. View the original on cms.gov.
Revision history
01/2024 - Transmittal 12318 issued October 19, 2023, is being rescinded and replaced by Transmittal 12441, dated January 3, 2024, to add FISS to BR 13390.11 and to add clarifying verbiage to business requirement 13390.12. All other information remains the same. ( TN 12441 ) (CR13390)
10/2023 - The purpose of this Change Request (CR) is to provide a quarterly maintenance update of ICD-10 coding conversions and other coding updates specific to National Coverage Determinations (NCDs). No policy is being changed as a result of these updates. ( TN 12318 ) (CR13390)
08/2022 - Transmittal 11545 dated August 5, 2022, is being rescinded and replaced by Transmittal 11584, dated, August 31, 2022. ( TN 11584 ) (CR12822)
08/2022 - The purpose of this Change Request (CR) is to provide a maintenance update of ICD-10 conversions and other coding updates to specific NCDs. ( TN 11545 ) (CR12822)
06/2022 - Transmittal 11400, dated May 4, 2022, is being rescinded and replaced by Transmittal 11460, dated, June 17, 2022, to update NCD 90.2, NGS, spreadsheet to conform with changes in CR 12124, and change the implementation date for all business requirements except 12705.6 to 30 days from issuance of this correction. All other information remains the same.( TN 11460 ) (CR12705)
05/2022 - This Change Request (CR) constitutes a maintenance update of ICD-10 conversions and other coding updates specific to NCDs. These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received. ( TN 11400 ) (CR12705)
01/2022 - Transmittal 11068, dated October 21, 2021, is being rescinded and replaced by Transmittal 11179, dated, January 12, 2022 to revise the attachment for NCD 110.24, CAR-T, to add business requirement 12480.10.1 by adding generic unspecified procedure codes, to clarify coverage and claims processing in the policy section and to review the implementation date. All other information remains the same. ( TN 11179 ) (CR12480)
10/2021 - This Change Request (CR) constitutes a maintenance update of ICD-10 conversions and other coding updates specific to NCDs. These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received. ( TN 11068 ) (CR12480)
05/2019 - This Change Request (CR) constitutes a maintenance update of ICD-10 conversions and other coding updates specific to NCDs. These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.
Previous NCD coding changes appear in ICD-10 quarterly updates that can be found at https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/ICD10.html , along with other CRs implementing new policy NCDs. Edits to ICD-10 and other coding updates specific to NCDs will be included in subsequent quarterly releases and individual CRs as appropriate. No policy-related changes are included with the ICD-10 quarterly updates. Any policy-related changes to NCDs continue to be implemented via the current, long-standing NCD process.( TN 2298 ) (CR11229)
05/2017 - This change request (CR) constitutes a maintenance update of ICD-10 conversions and other coding updates specific to national coverage determinations (NCDs). These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.
Previous NCD coding changes appear in ICD-10 quarterly updates that can be found at: https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/ICD10.html , along with other CRs implementing new policy NCDs. Edits to ICD-10 and other coding updates specific to NCDs will be included in subsequent, quarterly releases and individual CRs as appropriate. No policy-related changes are included with the ICD-10 quarterly updates. Any policy-related changes to NCDs continue to be implemented via the current, long-standing NCD process. ( TN 1854 ) (CR10086)
02/2017 - This change request (CR) is the 11th maintenance update of ICD-10 conversions and other coding updates specific to national coverage determinations (NCDs). These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.
Previous NCD coding changes appear in ICD-10 quarterly updates as follows: CR7818, CR8109, CR8197, CR8691, CR9087, CR9252, CR9540, CR9631, CR9751, and CR9861, as well as in CRs implementing new policy NCDs. Edits to ICD-10 and other coding updates specific to NCDs will be included in subsequent, quarterly releases and individual CRs as appropriate. No policy-related changes are included with the ICD-10 quarterly updates. Any policy-related changes to NCDs continue to be implemented via the current, long-standing NCD process. ( TN 1798 ) (CR9982)
03/2013 - CMS translated the information for this policy from ICD-9-CM/PCS to ICD-10-CM/PCS according to HIPAA standard medical data code set requirements and updated any necessary and related coding infrastructure. These updates do not expand, restrict, or alter existing coverage policy. Implementation date: 10/07/2013 Effective date: 10/1/2015. ( TN 1199 ) ( TN 1199 ) (CR 8197)
09/2010 - Effective for claims with dates of service August 12, 2010, and after, CMS has determined that the Ornish Program for Reversing Heart Disease and the Pritikin Program each meet the ICR program requirements set forth by Congress in section 1861(eee)(4)(A) of the Social Security Act and in regulations at 42 CFR 410.49(c) and, as such, both programs have been included on the list of approved ICR programs available at http://www.cms.gov/MedicareApprovedFacilitie/ . Effective date 08/12/2010 Implementation date 10/25/2010 ( TN 125 ) (CR 7113)
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 20.31.1
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 20.31.1
What does NCD 20.31.1 cover?
Effective for claims with dates of service on and after August 12, 2010, the Pritikin Program meets the intensive cardiac rehabilitation (ICR) program requirements set forth by Congress in §1861(eee)(4)(A) of the Social Security Act and in regulations at 42 C.F.R. §410.49(c) and, as such, has been included on the list of approved ICR programs available at http://www.cms.gov/Medicare/Medicare-General-Information… The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database.
When did NCD 20.31.1 take effect?
The current version (1) is effective 08/12/2010, implemented 10/25/2010, published in transmittal 125. This is the only published version.
Does a Local Coverage Determination override NCD 20.31.1?
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 2026-10-09. Verify against the primary file before billing or contracting decisions. The reference methodology explains how each figure is computed from these files.
- 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.
Found a figure that does not match the CMS file? Report a data correction with the CMS file and the value you expected; the request reaches the editorial team through the contact form.