(1) Pulmonary rehabilitation services are limited to the following:

(a) a maximum of 36 hours over a period not less than two weeks and not more than six weeks, limited to one of the following diagnoses:

(i) persistent asthma;

(ii) emphysema;

(iii) chronic bronchitis;

(iv) bronchiectasis;

(v) interstitial lung disease; and

(vi) chronic airway obstruction.

(2) If applicable, the patient must have ceased smoking or be in a smoking cessation class.

(3) The following pulmonary rehabilitation services are not covered:

(a) education, treatment, and therapies that are not individualized to a specific patient need or are not an integral part of the treatment session;

(b) routine psychological screening and treatment where intervention is not indicated;

(c) films/videos;

(d) duplicate services;

(e) maintenance care when there is no expectation of further improvement;

(f) treatment that is not medically necessary because the patient requires a general strengthening and endurance program only; and

(g) treatment that is not medically necessary because the patient is at an early stage of pulmonary disease as demonstrated by a lack of significant findings in diagnostic testing.