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Medical Policy: 01.01.04
Original Effective Date: December 1993
Reviewed: December 2011
Revised: September 2009
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy 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 will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Physical therapy of joints following surgery focuses on passive motion to restore mobility and active exercises to restore strength. Continuous passive motion (CPM) devices are frequently applied in the immediate post-operative period. CPM is thought to improve recovery by stimulating the healing of articular tissues and circulation of synovial fluid, reduce local edema, and prevent joint stiffness, adhesions, or cartilage degeneration. CPM has been shown to be efficacious in post-ACL reconstruction management in the presence of potentially complicating co-morbidities.
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Prior Approval:
Not applicable
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Policy:
Continuous Passive Motion Devices (CPM) may be considered medically necessary in the following situations, when the device is initiated within the 48-hour period following surgery:
- Total Knee Arthroplasty (TKA)
- Open reduction and internal fixation of tibial plateau or distal femur fractures involving the knee joint
- Knee arthrofibrosis occurring after Total Knee Arthroplasty (TKA) and requiring manipulation under general anesthesia
- Post operative rehabilitation after ACL reconstruction
Continuous Passive Motion devices (CPM) may be considered medically necessary during the non-weight bearing rehabilitation period following intra-articular cartilage repair procedures of the knee:
- Microfracture; or
- osteochondral grafting; or
- autologous chondrocyte implantation; or
- treatment of osteochondritis dissecans; or
- repair of tibial plateau fractures
CPM devices are payable only as rental equipment for 30 days following surgery.
The use of CPM devices is considered investigational in the following circumstances:
- Treatment of acute or chronic low back pain
- For any joint other than the knee
- For any condition of the knee other than those described above
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- E0935 Continuous passive motion exercise device for use on knee only
- E0936 Continuous passive motion exercise device for use other than knee
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Selected References:
- Continuous passive motion as an adjunct to physical therapy for joint rehabilitation. Blue Cross Blue Shield Association. TEC Assessment Program, v.11, n.20, January 1997.
- Adams KM, Thompson ST. Continuous passive motion use in hand therapy. Hand Clinics. 1996; 12(1):109-27.
- McCarthy MR, Yates CK, Anderson MA, et al. The effects of immediate continuous passive motion on pain during inflammatory phase of soft tissue healing following antreior cruciate ligament reconstruction. Journal of Orthopaedic and Sports Physical Therapy. 1993; 17(2):96-101.
- 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):1423-8.
- O'Driscoll SW, Giori NJ. Continuous passive motion (CPM): theory and principles of clinical application. Journal of Rehabilitation Research and Development. 2000; 37(2):179-88.
- Rosen MA, Jackson DW, Atwell EA. The efficacy of continuous passive motion in the rehabilitation of anterior cruciate ligament reconstructions. American Journal of Sports Medicine. 1992; 20:122-7.
- Ververeli PA, Sutton DC, Hearn SL, et al. Continuous passive motion after total knee arthroplasty. Clinical Orthopaedics and related research. 1995; 321:208-15.
- Davies DM, Johnston DW, Beaupre LA, Lier DA. Effect of adjunctive range-of-motion therapy after total knee arthroplasty on the use of health services after hospital discharge. Can J Surg. 2003 Feb; 46(1):30-6.
- McNair PJ, Dombroski EW, Hewson DJ, Stanley SN. Stretching at the ankle joint: viscoelastic responses to holds and continuous passive motion. Med Sci Sports Exerc. 2001 Mar; 33(3):354-8.
- Lastayo PC, Wright T, Jaffe R, Hartzel J. Continuous passive motion after repair of rotator cuff. A prospective outcome study. J Bone Joint Surg Am. 1998 Jul; 80(7):1002-11.
- Raab MG, Rzeszutko D, O'Connor W, Greatting MD. Early results of continuous passive motion after rotator cuff repair: a prospective, randomized, blinded, controlled study. Am J orthop, 1996 Mar; 25(3):214-20.
- Engstrom B, Sperber A, Wredmark T. Continuous passive motion in rehabilitation after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Anthrosc. 1995; 3(1): 18-20.
- Bennett LA, et al A comparison of 2 continuous passive motion protocols after total knee arthroplasty: a controlled and randomized study. J Arthroplasty. 2005 Feb;20(2):225-33.
- 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.
- ECRI Institute. Continuous Passive Motion Devices following Orthopedic Surgery. Plymouth Meeting (PA): ECRI Institute; 2009 April 2. 11p. [ECRI hotline response]. Also available: http://www.ecri.org.
- Fazalare JA, Griesser JH, Siston RA, Flanagan DC. The use of continuous passive motion following knee cartilage defect surgery: a systematic review. Orthopedics. 2010 Dec 1;33(12):878.
- 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 Apr;25(4):291-302.
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Policy History:
Date Reason Action
December 2010 Annual review Policy renewed
December 2011 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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