Clinical UM Guideline

This document addresses the use of pulmonary rehabilitation for the treatment of various lung conditions. Pulmonary rehabilitation (PR) is an individually tailored multidisciplinary program of care for people with chronic respiratory impairment.

Medically Necessary:

Pulmonary rehabilitation (PR) is considered medically necessary in individuals who meet the following criteria:

1. Individual is preparing for or recovering from surgical interventions such as:
   1. Lung transplantation; or
   2. Lung volume reduction surgery; or
   3. Post-operative states; (for example, thoracic or abdominal surgery).
      or
2. Individual has any of the following conditions:
   1. Chronic obstructive pulmonary disease such as:
      1. Asthma; or
      2. Bronchiectasis; or
      3. Chronic bronchitis; or
      4. Cystic fibrosis; or
      5. Emphysema; or
   2. Restrictive diseases such as:
      1. Chest wall disease; or
      2. Interstitial disease; or
      3. Post-polio syndrome; or
      4. Selected neuromuscular disorders; or
      5. Thoracic cage abnormalities; or
   3. Stable lung cancer;
      and
3. Individual continues to have disabling dyspnea despite optimal medical management associated with the following:
   1. A restriction in ordinary activities: and
   2. Significant impairment in quality of life;
      and
4. Individual is motivated to participate in a PR program;
   and
5.  Individual is free from the following (1 and 2 below):
   1. Conditions that may interfere with the individual undergoing the rehabilitative process, including but not limited to:
      1. Advanced arthritis; or
      2. Disruptive behavior; or
      3. Inability to learn;
         and
   2. Conditions that may place the individual at undue risk during exercise training, including but not limited to:
      1. Recent myocardial infarction; or
      2. Severe pulmonary hypertension; or
      3. Unstable angina.

Repeat PR programs may be considered medically necessary for individuals undergoing a second PR program in connection with lung transplantation or lung volume reduction surgery when medical necessity criteria for PR are met.

Not Medically Necessary:

PR provided in the inpatient setting is considered not medically necessary when medical necessity criteria for PR are not met.

Place of Service: Ambulatory/Outpatient
Duration: Frequency and duration of the program may vary according to the individual’s needs. It is not uncommon for the individual to receive therapy 3 times per week for 4 to 6 weeks.

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met:

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met.

According to the American Thoracic Society (ATS) pulmonary rehabilitation is defined as:

A comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies, which include, but are not limited to, exercise training, education, and behavior change, designed to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long-term adherence of health-enhancing behaviors.

The PR program combines an accurate diagnosis with therapy, emotional support, and education to stabilize or reverse both the physio- and psychopathology of pulmonary disease.

The goal of PR is to:

• Restore the individual to the highest possible level of independent function.
• Educate the individual and significant others about the disease, treatment options, and coping strategies.
• Encourage individuals to be actively involved in providing for their own healthcare and to be more independent in activities of daily living (ADL).

Several studies have demonstrated important benefits of PR including reducing dyspnea (shortness of breath) and improving exercise capacity, total energy expenditure, and quality of life (QOL) (Dodd, 2012; Dowman, 2021; Egan, 2012; Higashimoto, 2020; Mandal, 2012; McFarland, 2012). A number of studies have demonstrated that PR has also been associated with decreases in hospitalization rates and the overall utilization of medical resources. A randomized trial conducted by Ries, and colleagues (2005) demonstrated a non-significant trend for PR to increase 5-year survival. Mandal and colleagues (2012) conducted a pilot randomized controlled trial (RCT) with 30 subjects with non-cystic fibrosis bronchiectasis. The primary outcome measure was the incremental shuttle walking test (ISWT). Study authors reported no benefit for subjects in the control group, who received chest physiotherapy only, at the end of 8 weeks of therapy, or at 20 weeks post-therapy. Subjects in the experimental group, who received chest physiotherapy in conjunction with PR, demonstrated significant benefits (relative to baseline values) on ISWT (p=0.03), endurance walk test (EWT) (p=0.01), Leicester Cough Questionnaire (LCQ) (p<0.001), and St. George's Respiratory Questionnaire (SGRQ) (p<0.001). At 12 weeks following the last training session, the experimental group also showed continued and significant improvement (relative to baseline values) for ISWT (p=0.04) and EWT (p=0.003). LCQ and SGRQ also were significantly improved compared with baseline (p<0.001 for both measures). Limitations of this study included the lack of statistical comparisons between treatment and control groups, small study population, lack of blinding, and lack of clinically relevant primary outcome measures. Additional well-designed RCTs are necessary to confirm these initial findings.

An RCT by Lai and colleagues (2017) compared a preoperative, high-intensity, 7-day pulmonary rehabilitation program to standard care for 101 subjects preparing for lung cancer lobectomy. The primary endpoint was postoperative complications within 30 days of surgery, including atelectasis, acute respiratory distress syndrome, respiratory failure, mechanical ventilation, deep vein thrombosis/pulmonary embolism, and empyema/pneumonia. The researchers found that postoperative complications were significantly lower in the pulmonary rehabilitation group compared to the standard care group (5/51, 9.8% versus 14/50, 28%; p=0.019). In addition, the pulmonary rehabilitation group was able to walk further in 6 minutes (22.9 ± 25.9 m versus 4.2 ± 9.2 m), had better peak expiratory flow (increase of 25.2 ± 24.6 l/min versus 4.2 ± 7.7 l/min), and had a shorter postoperative hospital stay (6.1 ± 3.0 versus 8.7 ± 4.6 days; p=0.001). A total of 6 subjects did not complete the 7-day pulmonary rehabilitation program due to needing surgery early (2 cases), lack of endurance (2 cases), and perceived lack of benefit (2 cases). Overall, the researchers concluded that individuals with lung cancer benefit from a high-intensity, systematic, preoperative pulmonary rehabilitation program and have fewer postoperative complications.

In a joint consensus statement by the American Thoracic Society and the European Respiratory Society (2015), the following statement was made:

PR has demonstrated effectiveness for several respiratory conditions other than COPD. Randomized controlled trials demonstrating its beneficial effects on exercise capacity, symptoms, and/or health-related quality of life are available in interstitial lung disease, bronchiectasis, asthma, cystic fibrosis, lung transplantation, lung cancer, and pulmonary hypertension.

In a joint guideline published by the American College of Chest Physicians and the Canadian Thoracic Society (2016), the following recommendations were made for individuals with severe, or very severe COPD:

• …a recent exacerbation (for example, ≤ 4 weeks), we recommend pulmonary rehabilitation to prevent acute exacerbations of COPD (Grade 1C)
• …an exacerbation greater than the past 4 weeks, we do not suggest pulmonary rehabilitation to prevent acute exacerbations of COPD (Grade 2B)

In a joint guideline by the American Thoracic Society and the European Respiratory Society (Wedzicha, 2017), the following statement was made:

Pulmonary rehabilitation implemented within 3 weeks after discharge following a COPD exacerbation reduces hospital admissions and improves quality of life, while pulmonary rehabilitation implemented within 8 weeks after discharge increases exercise capacity.

Effective January1, 2022 the Center for Medicare Services issued a final rule which requires pulmonary rehabilitation coverage for beneficiaries with confirmed or suspected COVID-19 who experience persistent symptoms that include respiratory dysfunction for at least four weeks.

Li and colleagues (2021) reported the results of a parallel-group, randomised controlled trial, with 1:1 block randomization of 120 previously hospitalized COVID-19 survivors with complaints of lingering dyspnea. The study investigated whether survivors in a 6-week telerehabilitation program (n=59) via smartphone, and remotely monitored with heart rate telemetry, could improve functional exercise capacity, pulmonary function, lower limb muscle strength, health related quality of life, and dyspnea versus no rehabilitation (control n=61). The study demonstrated that 6-minute walking distance in the control group increased by 17.1 m from baseline at 6-week post-treatment assessment, whereas 6-minute walking distance in the treatment group improved by 80.2 m. The adjusted between-group difference in change from baseline was 65.45 m (p<0.001). Additionally, lower muscle strength was measured via static squat test in how many seconds participants could remain in the squatting position. This measurement also improved to a greater degree in the treatment group as compared with the control group. Squat test times were 20.12s post-treatment (p<0.001), and 22.23s (p<0.001) at 24-week follow-up. Lung function also improved in both groups. However, no differences were found between groups apart from a change from baseline of 10.57 L/min (p=0.005) in post-treatment maximum voluntary ventilation (MVV) in the treatment group. Health related quality of life as measured by the Short Form Health Survey-12 and Modified Medical Council Dyspnea Scale, also increased to a greater degree in the treatment group at post-treatment 3.79 points (p=0.004) and 2.69 points at follow-up (p=0.045), with 90.4% being dyspnea-free in the treatment group as opposed to 61.7% in the control group (p=0.001). Interestingly, a treatment effect for on dyspnea was found immediately after the treatment but not at follow up. No serious adverse events occurred during the study. Eight individuals (5 in the treatment and 3 in the control group) were hospitalized, all for non-life-threatening reasons unrelated to COVID-19 or the intervention and all in the follow-up period. The authors concluded that the telerehabilitation program was superior over not intervention with regard to functional exercise capacity, lower muscle strength, and physical health related quality of life. Short term effects were found for self-reported dyspnea and MVV. The effects of the program on pulmonary function are otherwise unlikely and effects on the mental aspects of quality of life are small at best.

Hockele and colleagues (2022) also reported the results of a clinical trial which studied the effects of pulmonary and physical rehabilitation on functional capacity via six-minute walk test, pulmonary function measured by spirometry, respiratory muscle strength by manovacuometry, handgrip strength by dynamometry, quality of life by the COPD Assessment Test, and functional status by the Post Covid Functional Status Test. Twenty-nine (n=29) individuals diagnosed with post-COVID-19 mild, moderate, or severe involvement by chest tomography, underwent 16 sessions in a rehabilitation program. After testing participants performed inspiratory muscle training exercises (IMT), aerobic exercise and peripheral muscle strength exercises, standardized by a protocol two times per week, for 60 min each. After two months of treatment, participants were reassessed to measure their individual improvements. The functional capacity increased in meters walked from 326.3 ± 140.6 to 445.4 ± 151.1 (p< 0.001), with an increase in the predicted value from 59.7% to 82.6% (p< 0.001). The lung function increased in liters from 2.9 ± 0.8 to 3.2 ± 0.8 (p=0.004) for forced vital capacity and from 2.5 ± 0.7 to 2.7 ± 0.7 (p=0.001) for forced expiratory volume in the first second. The respiratory muscle strength increased in cmH2O from 101.4 ± 46.3 to 115.8 ± 38.3 (p=0.117) for inspiratory pressure and from 85.8 ± 32.8 to 106.7 ± 36.8 (p<0.001) for expiratory pressure. The authors concluded that the program provided an improvement in all domains for the participants, restoring their quality of life.
Multiple systematic reviews have been published that support the efficacy of PR in managing COPD-related illnesses (Gordon, 2019; Lee, 2016; Lee, 2019; Mantoani, 2016; Meshe, 2016; Paneroni, 2017; Yang, 2019; Yu, 2019) including a Cochrane Review which included 20 studies representing a total of 1477 individuals (Puhan, 2016).

Frequency and duration of the program may vary according to the individual’s needs. It is not uncommon for the person to receive therapy 3 times per week for 4 to 6 weeks.

The permanence of outcomes achieved by PR appears to be more related to the structure and duration of the supervised maintenance component of the program than the intensity of the program. The long-term outcome data are somewhat limited in this respect. To achieve sustained results, it is important that the person continues with the at-home regimen outlined in the PR program.

There is currently no evidence that repeat pulmonary rehabilitation programs result in additive long-term benefits in terms of dyspnea, exercise tolerance, or health-related quality of life (HR-QOL) measures.

Peer Reviewed Publications:

1. Busby AK, Reese RL, Simon SR. Pulmonary rehabilitation maintenance interventions: a systematic review. Am J Health Behav. 2014; 38(3):321-330.
2. Carr SJ, Hill K, Brooks D, Goldstein RS. Pulmonary rehabilitation after acute exacerbation of chronic obstructive pulmonary disease in patients who previously completed a pulmonary rehabilitation program. J Cardiopulm Rehabil Prev. 2009; 29(5):318-324.
3. Cejudo P, López-Márquez I, López-Campos JL, et al. Exercise training in patients with chronic respiratory failure due to kyphoscoliosis: a randomized controlled trial. Respir Care. 2014; 59(3):375-382.
4. Di Meo F, Pedone C, Lubich S, et al. Age does not hamper the response to pulmonary rehabilitation of COPD patients. Age Ageing. 2008; 37(5):530-535.
5. Dodd JW, Marns PL, Clark AL, et al. The COPD Assessment Test (CAT): short- and medium-term response to pulmonary rehabilitation. COPD. 2012; 9(4):390-394.
6. Dowman LM, McDonald CF, Hill CJ, et al. The evidence of benefits of exercise training in interstitial lung disease: a randomised controlled trial. Thorax. 2017; 72(7):610-619.
7. Egan C, Deering BM, Blake C, et al. Short term and long term effects of pulmonary rehabilitation on physical activity in COPD. Respir Med. 2012; 106(12):1671-1679.
8. Ferguson GT. Recommendations for the management of COPD. Chest. 2000; 117(2 Suppl):23S-28S.
9. Foglio K, Bianchi L, Ambrosino N. Is it really useful to repeat outpatient pulmonary rehabilitation programs in patients with chronic airway obstruction? A 2-year controlled study. Chest. 2001; 119(6):1696-1704.
10. Gordon CS, Waller JW, Cook RM, et al. Effect of pulmonary rehabilitation on symptoms of anxiety and depression in COPD: a systematic review and meta-analysis. Chest. 2019; 156(1):80-91.
11. Griffiths TL, Phillips CJ, Davies S, et al. Cost effectiveness of an outpatient multidisciplinary pulmonary rehabilitation programme. Thorax. 2001; 56(10):779-784.
12. Higashimoto Y, Ando M, Sano A, et al. Effect of pulmonary rehabilitation programs including lower limb endurance training on dyspnea in stable COPD: a systematic review and meta-analysis. Respir Investig. 2020; 58(5):355-366.
13. Hockele LF, Sachet Affonso JV, Rossi D, et al. Pulmonary and functional rehabilitation improves functional capacity, pulmonary function and respiratory muscle strength in post COVID-19 patients: pilot clinical trial. Int J Environ Res Public Health. 2022;19(22):14899.Hoffman M, Chaves G, Ribeiro-Samora GA, et al. Effects of pulmonary rehabilitation in lung transplant candidates: a systematic review. BMJ Open. 2017; 7(2):e013445.
14. Kaplan RM, Ries AL, Reilly J, Mohsenifar Z. Measurement of health-related quality of life in the national emphysema treatment trial. Chest. 2004; 126(3):781-789.
15. Ketelaars CA, Abu-Saad HH, Schlosser MA, et al. Long-term outcome of pulmonary rehabilitation in patients with COPD. Chest. 1997; 112(2):363-369.
16. Lai Y, Su J, Qui P, et al. Systematic short-term pulmonary rehabilitation before lung cancer lobectomy: a randomized trial. Interact Cardiovasc Thorac Surg. 2017; 25(3):476-483.
17. Lee AL, Hill CJ, McDonald CF, Holland AE. Pulmonary rehabilitation in individuals with non-cystic fibrosis bronchiectasis - a systematic review. Arch Phys Med Rehabil. 2017; 98(4):774-782.
18. Lee EN, Kim MJ. Meta-analysis of the effect of a pulmonary rehabilitation program on respiratory muscle strength in patients with chronic obstructive pulmonary disease. Asian Nurs Res (Korean Soc Nurs Sci). 2019; 13(1):1-10.
19. Li J, Xia W, Zhan C, et al. A telerehabilitation programme in post-discharge COVID-19 patients (TERECO): a randomised controlled trial. Thorax. 2022;77(7):697-706.
20. Mahler DA. Pulmonary rehabilitation. Chest. 1998; 113(4 Suppl):263S-268S.
21. Maltais F, Bourbeau J, Shapiro S, et al. Effects of home-based pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: a randomized trial. Ann Intern Med. 2008; 149(12):869-878.
22. Mandal P, Sidhu MK, Kope L, et al. A pilot study of pulmonary rehabilitation and chest physiotherapy versus chest physiotherapy alone in bronchiectasis. Respir Med. 2012; 106(12):1647-1654.
23. Mantoani LC, Rubio N, McKinstry B, et al. Interventions to modify physical activity in patients with COPD: a systematic review. Eur Respir J. 2016; 48(1):69-81.
24. McFarland C, Willson D, Sloan J, Coultas D. A randomized trial comparing 2 types of in-home rehabilitation for chronic obstructive pulmonary disease: a pilot study. J Geriatr Phys Ther. 2012; 35(3):132-139.
25. Meshe OF, Claydon LS, Bungay H, Andrew S. The relationship between physical activity and health status in patients with chronic obstructive pulmonary disease following pulmonary rehabilitation. Disabil Rehabil. 2016; 39(8):746-756.
26. Moore E, Newson R, Joshi M, et al. Effects of pulmonary rehabilitation on exacerbation number and severity in people with COPD: an historical cohort study using electronic health records. Chest. 2017; 152(6):1188-1202.
27. Morano MT, Mesquita R, Da Silva GP, et al. Comparison of the effects of pulmonary rehabilitation with chest physical therapy on the levels of fibrinogen and albumin in patients with lung cancer awaiting lung resection: a randomized clinical trial. BMC Pulm Med. 2014; 14:121.
28. Paneroni M, Simonelli C, Vitacca M, Ambrosino N. Aerobic exercise training in very severe chronic obstructive pulmonary disease: a systematic review and meta-analysis. Am J Phy Med Rehabil. 2017; 96(8):541-548.
29. Ries AL, Make BJ, Lee SM, et al.; National Emphysema Treatment Trial Research Group. The effects of pulmonary rehabilitation in the national emphysema treatment trial. Chest. 2005; 128(6):3799-3809.
30. Salhi B, Huysse W, Van Maele G, et al. The effect of radical treatment and rehabilitation on muscle mass and strength: a randomized trial in stages I-III lung cancer patients. Lung Cancer. 2014; 84(1):56-61.
31. San Pedro GS. Pulmonary rehabilitation for the patient with severe chronic obstructive pulmonary disease. Am J Med Sci. 1999; 318(2):99-102.
32. von Leupoldt A, Hahn E, Taube K, et al. Effects of 3-week outpatient pulmonary rehabilitation on exercise capacity, dyspnea, and quality of life in COPD. Lung. 2008; 186(6):387-391.
33. Waterhouse JC, Walters SJ, Oluboyede Y, Lawson RA. A randomised 2 x 2 trial of community versus hospital pulmonary rehabilitation, followed by telephone or conventional follow-up. Health Technol Assess. 2010; 14(6):i-v, vii-xi, 1-140.
34. Yang J, Lin R, Xu Z, Zhang H. Significance of pulmonary rehabilitation in improving quality of life for subjects with COPD. Respir Care. 2019; 64(1):99-107.
35. Yu X, Li X, Wang L, Liu R, et al. Pulmonary rehabilitation for exercise tolerance and quality of life in IPF patients: a systematic review and meta-analysis. Biomed Res Int. 2019; Mar 21;2019:8498603.

Government Agency, Medical Society, and Other Authoritative Publications:

1. Agency for Healthcare Quality and Research. Pulmonary rehabilitation for COPD and other lung diseases. November 21, 2006. Available at: http://www.cms.gov/Medicare/Coverage/DeterminationProcess/‌downloads/id43TA.pdf. Accessed on May 15,  2023.
2. American College of Chest Physicians and Canadian Thoracic Society. Guidelines: Prevention of acute exacerbations of COPD. 2015. Available at: http://journal.chestnet.org/article/S0012-3692(15)38941-8/abstract. Accessed on May 15,  2023.
3. American Thoracic Society. Pulmonary Rehabilitation. Available at: https://www.thoracic.org/statements/pulmonary-rehab.php. Accessed on May 15,  2023.
4. Center for Disease Control and Prevention. Health Topics: Chronic Obstructive Pulmonary Disease (COPD). Last reviewed October 21, 2022. Available at; https://www.cdc.gov/copd/features/copd-symptoms-diagnosis-treatment.html. Accessed on May 15, 2023.
5. Centers for Medicare and Medicaid Services. National Coverage Determination. Available at https://www.cms.gov/medicare-coverage-database/new-search/search.aspx. Accessed May 15, 2023.
   • Lung Volume Reduction Surgery (Reduction Pneumoplasty). NCD #240.1. Effective November 17, 2005.
   • Pulmonary Rehabilitation. NCD #240.8. Effective September 25, 2007.
6. Collins EG, Bauldoff G, Carlin B, et al. Clinical competency guidelines for pulmonary rehabilitation professionals: position statement of the American Association of Cardiovascular and Pulmonary Rehabilitation. J Cardiopulm Rehabil Prev. 2014; 34(5):291-302.
7. Dowman L, Hill CJ, Holland AE. Pulmonary rehabilitation for interstitial lung disease. Cochrane Database Syst Rev. 2021;(10):CD006322.
8. McCarthy B, Casey D, Devane D et al. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2015;(2):CD003793.
9. Nici L, Donner C, Woulters E, et al. American Thoracic Society/European Respiratory Society Statement on Pulmonary Rehabilitation. Am J Respir Crit Care Med. 2006; 173(12):1390-1413. Available at: http://www.thoracic.org/statements/resources/respiratory-disease-adults/atserspr0606.pdf. Accessed on May 15,  2023.
10. Parshall MB, Schwartzstein RM, Adams L, et al.; American Thoracic Society Committee on Dyspnea. An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. Am J Respir Crit Care Med. 2012; 185(4):435-452.
11. Puhan MA, Gimeno-Santos E, Scharplatz M, et al. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Data Syst Rev. 2016;(10):CD005305.
12. Qaseem A, Wilt TJ, Weinberger SE, et al.; American College of Physicians; American College of Chest Physicians; American Thoracic Society; European Respiratory Society. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med. 2011; 155(3):179-191.
13. Ries AL, Bauldoff GS, Carlin BW, et al. Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines. Chest. 2007; 131(5 Suppl):4S-42S.
14. Rochester CL, Vogiatzis I, Holland AE, et al. An Official American Thoracic Society/European Respiratory Society Policy Statement: Enhancing implementation, use, and delivery of pulmonary rehabilitation. Am J Respir Crit Care Med. 2015; 192(11):1373-1386.
15. United States Department of Veterans Affairs/Department of Defense. VA/DoD clinical practice guidelines for the management of chronic obstructive pulmonary disease. December 2014. Available at: http://www.healthquality.va.gov/guidelines/CD/copd/VADoDCOPDCPG2014.pdf. Accessed on May 15,  2023.
16. Wedzicha JA, Miravitlles M, Hurst JR, et al. Management of COPD exacerbations: a European Respiratory Society/American Thoracic Society guideline. Eur Respir J. 2017; 49(3).

Asthma
Bronchiectasis
Chronic Bronchitis
Chronic Obstructive Pulmonary Disease
Chronic Respiratory Impairment
Cystic Fibrosis
Emphysema
Lung Transplantation
Lung Volume Reduction
Post-Polio Syndrome
Pulmonary Rehabilitation

This Clinical UM Guideline is intended to provide assistance in interpreting Healthy Blue’s standard Medicaid benefit plan. When evaluating insurance coverage for the provision of medical care, federal, state and/or contractual requirements must be referenced, since these may limit or differ from the standard benefit plan. In the event of a conflict, the federal, state and/or contractual requirements for the applicable benefit plan coverage will govern. Healthy Blue reserves the right to modify its Policies and Guidelines as necessary and in accordance with legal and contractual requirements. This Clinical UM Guideline is provided for informational purposes. It does not constitute medical advice. Healthy Blue may also use tools and criteria developed by third parties, to assist us in administering health benefits. Healthy Blue’s Policies and Guidelines are intended to be used in accordance with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice.