CMS Lauded for Coverage Decision on Supervised Exercise Therapy for PAD

The recent announcement from the Centers for Medicare & Medicaid Services (CMS) that they will cover supervised exercise for peripheral artery disease (PAD) is being hailed as a major victory in a long-fought battle.

“I can’t tell you how important this is,” said Michael Jaff, DO (Newton-Wellesley Hospital, Boston, MA), in an interview with TCTMD. “This is long overdue and ought to change the way patients with claudication and PAD are managed forever.”

Jaff, who has advocated for this type of coverage for two decades along with many other vascular specialists and organizations, said that since the decision he has received emails from physicians around the country asking how to proceed. His advice is to start slow on a treadmill at whatever pace an individual patient can tolerate.

I can’t tell you how important this is. Michael Jaff

“You don’t want them to start on day one and be so miserable they don’t want to come back,” he said. “So you have to start with something that’s easy. But many elderly people have [such] a fear of the treadmill that you first have to help them overcome by showing them that they can do this, they aren’t going to fall, it isn’t going to go too fast for them, etc.”

Additionally, Jaff said the 2016 American College of Cardiology/American Heart Association guidelines on the management of patients with lower extremity PAD is another good place for information on supervised exercise. For now, he suggested that many PAD exercise programs are likely to dovetail off existing cardiac rehabilitation. As time goes on, new protocols and suggestions may emerge, he added.

In a statement, the American Heart Association also applauded the move, saying the decision by CMS “will give more Americans the access they need to this important treatment option.” The association submitted a formal request to CMS last year asking for this outcome.

Encourage and Evaluate

The CMS Decision Memo, issued May 25, 2017, stipulates a number of criteria that must be met for supervised exercise therapy (SET) to be covered.

The SET program must:

• consist of sessions lasting 30-60 minutes;
• be conducted in a physician’s office or hospital outpatient setting;
• employ staff who are specifically trained in exercise therapy for PAD and qualified to ensure that the program delivers benefits that exceed any harms; and
• be under the direct supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist trained in both basic and advanced life support techniques.

Under the coverage decision, Medicare will pay for up to 36 sessions of supervised exercise ranging from 30 to 60 minutes each over a 12-week period, with the possibility of approval for an additional 36 sessions. To be eligible, beneficiaries must meet with their physician to obtain a prescription for supervised exercise. At the same visit, patients also must receive information regarding CVD and PAD risk-factor reduction.

Ultimately, Jaff said it will be up to physicians to stay on top of their PAD patients and evaluate how they respond to supervised exercise and whether they need to petition for an extension beyond the initial covered sessions.

“Or, if the patient actually feels like it didn’t help or in fact things have gotten worse, that would be important for the doctor to know as well,” he added. But Jaff said the worst thing that could happen is that patients and their physicians don’t use the coverage benefit enough for Medicare to consider it worthwhile.

“If patients participate in a Medicare-covered PAD rehab program, it ought to show them some clinical benefit,” he noted. “Their walking distance should improve, and the intensity of pain should lessen. The bottom line is [that] getting patients to do the supervised exercise will show them how it [can help them] and they will be motivated to continue it. That’s the hope.”