The recent Centers for Medicare & Medicaid Services (CMS) decision to cover supervised exercise therapy for symptomatic peripheral artery disease (PAD) and intermittent claudication will enable many patients to improve their walking ability without undergoing surgery or an interventional procedure. So say leading Cleveland Clinic vascular disease specialists.
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“Exercise is the single most effective therapy for claudication,” says Heather Gornik, MD, a cardiologist in Cleveland Clinic’s Section of Vascular Medicine and president of the Society for Vascular Medicine. “Research has shown over and over that supervised exercise increases both pain-free walking distance and total walking distance. It’s the first treatment that should be tried for these patients.”
Long time coming
Members of all relevant major medical and surgical societies had lobbied CMS for this coverage for about 15 years.
When Dr. Gornik served as vice chair of the writing committee for the American Heart Association/American College of Cardiology guidelines on PAD released in late 2016 (covered here), her committee gave exercise therapy a class I recommendation, putting it ahead of medications like cilostazol and revascularization for treatment of claudication. “It was a frustrating irony that patients could get an expensive stent while something as cost-effective and low-risk as exercise was not covered,” she says. “That’s why we are thrilled with this decision.”
Cleveland Clinic vascular surgeon Lee Kirksey, MD, shares that enthusiasm. “It’s very exciting,” he says. “You can get the same benefits with exercise as with a procedure — sometimes better. Not only can exercise save the cost of an expensive procedure, but patients often enjoy benefits in recovery of walking function and quality of life.”
A supervised exercise program can also permit patients who have already undergone revascularization to achieve maximal benefit by reconditioning their muscles, he notes.
What will be covered
The CMS coverage decision will allow for up to 36 physician-supervised sessions over a 12-week period. The sessions must be 30 to 60 minutes in length, conducted in a hospital outpatient setting or physician’s office, be delivered by qualified personnel and be supervised directly by a physician, physician assistant, nurse practitioner or clinical nurse specialist trained in life-support techniques.
Providers may see some variations in coverage upon receipt of local determinations.
Although the decision allows coverage to be extended for an additional 36 sessions at the discretion of CMS, Dr. Gornik feels the goal for most patients should be to complete 36 sessions and then transition the patient to a community- or home-based exercise program. “We want to empower patients to exercise on their own,” she says, a goal that’s possible after patients learn how exercise improves their ability to enjoy life and handle everyday tasks with less pain.
In support of exercise — with supervision
Cleveland Clinic has offered exercise therapy for PAD for years, but since the intervention was reimbursed by few commercial carriers, its use was limited. Following the lead of CMS, more carriers are likely to extend coverage to patients with PAD. However, the CMS decision itself is likely to have the largest impact, since PAD primarily affects patients in the Medicare-eligible 65-plus age cohort.
Exercise therapy for PAD involves treadmill walking to the point of fatigue, resting and then walking again. “The general thinking is that this stresses muscles so they use oxygen more efficiently and collateral blood flow increases,” Dr. Kirksey explains. “Over time, patients are able to walk further and longer before the onset of leg pain that characterizes intermittent claudication.”
A physician-supervised program encourages patients to push ahead through pain — something they are unlikely to do exercising independently. “We can tell patients to exercise in the same manner as a supervised exercise program, but in general, they won’t derive the same benefit,” Dr. Kirksey observes. “Many find their symptoms stay the same or get worse, and some patients will need surgery.”
Physician supervision also protects patients, he notes, since those with PAD are likely to have other forms of cardiovascular disease that may increase their risk of heart attack or stroke.