Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Continuous Passive Motion (CPM) Devices in the Home Setting

Policy #:05.00.08e

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

MEDICALLY NECESSARY

The use of continuous passive motion (CPM) devices may begin in a hospital setting. When a CPM device is used during an approved admission for another condition that meets the criteria for inpatient level of care, the device is incidental to the inpatient stay. A CPM device may be used post-discharge if an individual is unable to tolerate a physical therapy program.

A CPM device in the home setting is considered medically necessary and, therefore, covered as a rental item when the following medical necessity criteria are met:
  • The device is applied within seven days of a surgical procedure, and its use is limited to a maximum duration of 28 consecutive days following the date of the surgery. Authorization for a CPM device rental beyond 28 consecutive days should integrate an individual's range-of-motion (ROM) status in the decision-making process.
  • The individual will use the CPM unit in the home setting for the duration of treatment with the device.
  • The device is part of a therapy plan for any of the following conditions:
    • As postoperative therapy for any of the following knee procedures:
      • Total knee arthroplasty (TKR) (replacement or revision)
      • Anterior cruciate ligament (ACL) repair or reconstruction
      • Lysis of adhesions for arthrofibrosis
      • Open reduction of comminuted intra-articular fractures
      • Manipulation of the knee under anesthesia
      • Synovectomy
      • Articular cartilage grafting
    • As therapy for any of the following conditions OR postoperative hand procedures:
      • Dupuytren's disease with pain and/or edema that impedes active ROM
      • Joint collateral ligament release to the proximal interphalangeal (PIP) or metacarpophalangeal (MCP) joint
      • Flexor or extensor tenolysis with or without capsulectomy
      • Dorsal and/or volar injuries (e.g., severe crush injuries) in which tendinous repairs preclude active ROM
    • As a second-line adjunct when traditional therapeutic maneuvers for the hand fail to achieve meaningful or expected gains in digital ROM (e.g., failure to progress after two weeks of intensive supervised hand therapy) for the following conditions OR postoperative procedures:
      • Intra-articular fractures status post open reduction internal fixation (ORIF)
      • High-pressure injection injuries to the hand
      • Status post burns to the hand
      • Status post PIP or MCP arthroplasties

NOT MEDICALLY NECESSARY

All other uses for the CPM device in the home setting are considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support their use postoperatively for any other joint (e.g., ankle, jaw, hip, wrist, elbow, shoulder).

REQUIRED DOCUMENTATION

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports. This policy is consistent with Medicare's documentation requirements, including the following required documentation:

PRESCRIPTION (ORDER) REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective order at the time of an audit or after an audit for submission as an original order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier, and a signed copy of delivery confirmation by member/caregiver if delivered by the DME supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES
The durable medical equipment (DME) supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately seven days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual’s medical record. Delivery of the supplies should not be done earlier than approximately five days before the individual would exhaust their on-hand supply.

If required documentation is not available on file to support a claim at the time of an audit or record request, the durable medical equipment (DME) supplier may be required to reimburse the Company for overpayments.
Guidelines

Continuous passive motion (CPM) devices are covered by the Company on a daily rental basis only.

When bilateral procedures are performed, only one CPM device per rental period is covered.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, CPM devices are covered under the medical benefits of the Company’s products when the medical necessity criteria listed in the medical policy are met.

However, services that are identified in this policy as not medically necessary are not eligible for coverage or reimbursement by the Company.

PLACE OF SERVICE

This service is only eligible for reimbursement when performed in the home setting.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

The FDA has approved several CPM devices for multiple joints of the body. The FDA considers these to be Class I devices, which are exempt from premarket notification procedures.

Description

Continuous passive motion (CPM) devices provide mechanical passive range of motion (ROM) to joints (e.g., knees, hands) following surgery to maintain or restore strength, mobility, and functionality of articular tissues, cartilage, tendons, and ligaments. The device moves the joint (e.g., flexes and extends) continuously, without assistance from the individual, to promote healing by circulating synovial fluid while deterring adhesions, stiffness, and contractures. The affected joint is placed on the device and held in place by Velcro® straps. An electrical power unit is used to set a variable ROM and speed. The initial settings for ROM are based on the individual’s level of comfort and other factors that are assessed intraoperatively (e.g., initial degree of flexion and extension). Under the direction of the ordering health care professional, the ROM may be increased three to five degrees per day, depending on joint stability and individual comfort.

For CPM devices used following knee surgery (e.g., total knee arthroplasty [TKR]), the customary length of treatment following the procedure is between one and two weeks.

For CPM devices used following hand surgery (e.g., flexor or extensor tenolysis) when pain and/or edema impede active ROM, the average length of postoperative use is between two and four weeks.

CPM devices can also be used as second-line adjuncts when traditional therapeutic maneuvers for the hand fail to achieve meaningful or expected gains in digital ROM (e.g., status-post proximal interphalangeal [PIP] or metacarpophalangeal [MCP] arthroplasties, status post burns).

There is a paucity of literature to indicate that the use of CPM devices in the home setting for any other joint (e.g., ankle, shoulder, jaw, hip, wrist, elbow) is more advantageous than traditional methods of physical therapy.
References


Adams KM, Thompson ST. Continuous passive motion use in hand therapy. Hand Clin. 1996;12(1):109-127.

American Academy of Orthopaedic Surgeons. Surgical managment of osteoarthritis of the knee. Evidence-based clinical practice guideline. 2015; Available at: http://www.aaos.org/uploadedFiles/PreProduction/Quality/Guidelines_and_Reviews/guidelines/SMOAK%20CPG_4.22.2016.pdf . Accessed January 22, 2019.

Andersen NH, Sřjbjerg JO, Johannsen HV, Sneppen O. Frozen shoulder: arthroscopy and manipulation under general anesthesia and early passive motion. J Shoulder Elbow Surg. 1998;7(3):218-222.

Bentham JS, Brereton WD, Cochrane IW, Lyttle D. Continuous passive motion device for hand rehabilitation. Arch Phys Med Rehabil. 1987;68(4):248-250.

Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Continuous Passive Motion as an Adjunct to Physical Therapy for Joint Rehabilitation. TEC Assessments. 1997;Volume 12(Tab 20).

Boese CK, Weis M, Phillips T et al. The efficacy of continuous passive motion after total knee arthroplasty: a comparison of three protocols. J Arthroplasty. 2014; 29(6):1158-62.

Brosseau L, Milne S, Wells G, et al. Efficacy of continuous passive motion following total knee arthroplasty: a metaanalysis. J Rheumatol. 2004;31(11):2251-2264.

Browne JE, Anderson AF, Arciero R, et al. Clinical outcome of autologous chondrocyte implantation at 5 years in US subjects. Clin Orthop Relat Res. 2005(436):237-245.

Bruun-Olsen V, Heiberg KE, Mengshoel AM. Continuous passive motion as an adjunct to active exercises in early rehabilitation following total knee arthroplasty - a randomized controlled trial. Disabil Rehabil. 2009;31(4):277-283.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD).280.1: Durable medical equipment reference list. [CMS Web site]. 05/05/05. Available at:
http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=190&ncdver=2&bc=BAABAAAAAAAA&. Accessed January 22, 2019.

Chen B, Zimmerman JR, Soulen L, et al. Continuous passive motion after total knee arthroplasty: a prospective study. Am J Phys Med Rehabil. 2000;79(5):421-426.

Denis M, Moffet H, Caron F, et al. Effectiveness of continuous passive motion and conventional physical therapy after total knee arthroplasty: a randomized clinical trial. Phys Ther. 2006;86(2):174-185.

Dundar U, Toktas H, Cakir T, et al. Continuous passive motion provides good pain control in patients with adhesive capsulitis. Int J Rehabil Res. 2009;32(3):193-198.

Du Plessis M, Eksteen E, Jenneker A, et al. The effectiveness of continuous passive motion on range of motion, pain and muscle strength following rotator cuff repair: a systematic review. Clin Rehabil. 2011;25(4):291-302.

Farr J. Autologous chondrocyte implantation improves patellofemoral cartilage treatment outcomes. Clin Orthop Relat Res. 2007;463:187-194.

Fazalare JA, Griesser MJ, Siston RA, et al. The use of continuous passive motion following knee cartilage defect surgery: a systematic review. Orthopedics. 2010;33(12):878.

Gates HS 3rd, Sullivan FL, Urbaniak JR. Anterior capsulotomy and continuous passive motion in the treatment of post-traumatic flexion contracture of the elbow. A prospective study. J Bone Joint Surg Am. 1992;74(8):1229-1234.

Garofalo R, Conti M, Notarnicola A, et al. Effects of one-month continuous passive motion after arthroscopic rotator cuff repair: results at 1-year follow-up of a prospective randomized study. Musculoskelet Surg. 2010;94 Suppl 1:S79-83.

Gavish L, Barzilay Y, Koren C, et al. Novel continuous passive motion device for self-treatment of chronic lower back pain: a randomised controlled study. Physiotherapy. 2015;101(1):75-81.

Harvey LA, Brosseau L, Herbert RD. Continuous passive motion following total knee arthroplasty in people with arthritis. Cochrane Database Syst Rev. 2014; 2:CD004260.

He ML, Xiao ZM, Lei M, et al. Continuous passive motion for preventing venous thromboembolism after total knee arthroplasty. Cochrane Database Syst Rev. 2014;7:CD008207.

Herbold JA, Bonistall K, Blackburn M. Effectiveness of continuous passive motion in an inpatient rehabilitation hospital after total knee replacement: a matched cohort study. PM R. 2012; 4(10):719-725.

Herbold JA, Bonistall K, Blackburn M et al. Randomized Controlled Trial of the Effectiveness of Continuous Passive Motion After Total Knee Replacement. Arch Phys Med Rehabil. 2014.

Hill AD, Palmer MJ, Tanner SL, et al. Use of continuous passive motion in the postoperative treatment of intra-articular knee fractures. J Bone Joint Surg Am. 2014;96(14):e118.

Howard JS, Mattacola CG, Romine SE, et al. Continuous passive motion, early weight bearing, and active motion following knee articular cartilage repair: evidence for clinical practice. Cartilage. 2010;1(4):276-286.

Kasten P, Geiger F, Zeifang F, et al. Compliance with continuous passive movement is low after surgical treatment of idiopathic club foot in infants: a prospective, double-blinded clinical study. J Bone Joint Surg Br. 2007;89(3):375-377.

Kumar PJ, McPherson EJ, Dorr LD, et al. Rehabilitation after total knee arthroplasty: a comparison of 2 rehabilitation techniques. Clin Orthop Relat Res. 1996(331):93-101.

Lastayo PC, Wright T, Jaffe R, Hartzel J. Continuous passive motion after repair of the rotator cuff. A prospective outcome study. J Bone Joint Surg Am. 1998;80(7):1002-1011.

Leach W, Reid J, Murphy F. Continuous passive motion following total knee replacement: a prospective randomized trial with follow-up to 1 year. Knee Surg Sports Traumatol Arthrosc. 2006;14(10):922-926.

Lenssen TA, van Steyn MJ, Crijns YH, et al. Effectiveness of prolonged use of continuous passive motion (CPM), as an adjunct to physiotherapy, after total knee arthroplasty. BMC Musculoskelet Disord. 2008;9:60.

Lindenhovius AL, van de Luijtgaarden K, Ring D, et al. Open elbow contracture release: postoperative management with and without continuous passive motion. J Hand Surg Am. 2009;34(5):858-865.

Lynch D, Ferraro M, Krol J, et al. Continuous passive motion improves shoulder joint integrity following stroke. Clin Rehabil. 2005;19(6):594-599.

MacDonald SJ, Bourne RB, Rorabeck CH, et al. Prospective randomized clinical trial of continuous passive motion after total knee arthroplasty. Clin Orthop Relat Res. 2000(380):30-35.

McInnes J, Larson MG, Daltroy LH, et al. A controlled evaluation of continuous passive motion in patients undergoing total knee arthroplasty. JAMA. 1992;268(11):1423-1428.

Milne S, Brosseau L, Robinson V, et al. Continuous passive motion following total knee arthroplasty. Cochrane Database Syst Rev. 2003;(2):CD004260.

Nugent-Derfus GE, Takara T, O'Neill J K, et al. Continuous passive motion applied to whole joints stimulates chondrocyte biosynthesis of PRG4. Osteoarthritis Cartilage. 2007;15(5):566-574.

Pope RO, Corcoran S, McCaul K, et al. Continuous passive motion after primary total knee arthroplasty. Does it offer any benefits? J Bone Joint Surg Br. 1997;79(6):914-917.

Postel JM, Thoumie P, Missaoui B, et al. Continuous passive motion compared with intermittent mobilization after total knee arthroplasty. Elaboration of French clinical practice guidelines. Ann Readapt Med Phys. 2007;50(4):244-257.

Raab MG, Rzeszutko D, O'Connor W, et al. Early results of continuous passive motion after rotator cuff repair: a prospective, randomized, blinded, controlled study. Am J Orthop (Belle Mead NJ). 1996;25(3):214-220.

Rosenberger RE, Gomoll AH, Bryant T, et al. Repair of large chondral defects of the knee with autologous chondrocyte implantation in patients 45 years or older. Am J Sports Med. 2008;36(12):2336-2344.

Salter RB, Hamilton HW, Wedge JH, et al. Clinical application of basic research on continuous passive motion for disorders and injuries of synovial joints: a preliminary report of a feasibility study. J Orthop Res. 1984;1(3):325-342.

Schwartz DA, Chafetz R. Continuous passive motion after tenolysis in hand therapy patients: a retrospective study. J Hand Ther. 2008;21(3):261-266; quiz 267.

Simkin PA, de Lateur BJ, Alquist AD, et al. Continuous passive motion for osteoarthritis of the hip: a pilot study. J Rheumatol. 1999;26(9):1987-1991.

Soffer SR, Yahiro MA. Continuous passive motion after internal fixation of distal humerus fractures. Orthop Rev. 1990;19(1):88-93.

Thompson ST, Wehbé MA. Early motion after wrist surgery. Hand Clin. 1996;12(1):87-96.

Worland RL, Arredondo J, Angles F, et al. Home continuous passive motion machine versus professional physical therapy following total knee replacement. J Arthroplasty. 1998:13(7):784-787.

Wright RW, Preston E, Fleming BC, et al. A systematic review of anterior cruciate ligament reconstruction rehabilitation: part I: continuous passive motion, early weight bearing, postoperative bracing, and home-based rehabilitation. J Knee Surg. 2008;21(3):217-224.

Yashar AA, Venn-Watson E, Welsh T, et al. Continuous passive motion with accelerated flexion after total knee arthroplasty. Clin Orthop Relat Res.1997(345):38-43.

Zeifang F, Carstens C, Schneider S, et al. Continuous passive motion versus immobilisation in a cast after surgical treatment of idiopathic club foot in infants: a prospective, blinded, randomised, clinical study. J Bone Joint Surg Br. 2005;87(12):1663-1665.





Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)



E0935 Continuous passive motion exercise device for use on knee only

E0936 Continuous passive motion exercise device for use other than knee


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

05.00.08e
02/27/2019This policy has been updated to communicate the Company’s continuing position on Continuous Passive Motion (CPM) Devices in the Home Setting.
03/07/2018This version of the policy will become effective 03/07/2018. This policy has been updated to communicate the Company’s continuing position on Continuous Passive Motion (CPM) Devices in the Home Setting.


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 03/07/2018
Version Issued Date: 03/07/2018
Version Reissued Date: 02/27/2019

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