Medical Policy: 01.01.04
Original Effective Date: December 1993
Reviewed: September 2015
Revised: September 2015
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.
Continuous passive motion (CPM) device is a treatment modality designed to facilitate recovery following injury to or surgery on joint(s) or peri-articular tissues, including cartilage, tendons, and ligaments. CPM provides motion of joint at a consistent speed without patient assistance, using a motorized device that moves the affected joint through a prescribed arc of motion (flexion/extension). CPM devices are frequently applied in the immediate postoperative period and may be continued at home for a variable period of time.
Physical therapy of joints following surgery focuses on passive motion to restore mobility and active exercises to restore strength. While passive motion can be administered by a physical therapist, CPM devices have also been used. CPM is thought to improve recovery by stimulating the healing of articular tissues and circulation of synovial fluid; reducing local edema; and preventing joint stiffness or contractures, adhesions, or cartilage degeneration. Therefore, potential benefits of CPM may include short-term ROM gains, decreased development of DVT, decreased hospital length of stay, reduced cost compared with physical therapy (PT) alone and reduced postoperative use of analgesics.
Based on the peer reviewed literature most of the research on continuous passive motion (CPM) devices has been as a postoperative treatment for total knee arthroplasty (TKA) and ligamentous or cartilage repair of the knee. Studies conducted in a controlled hospital setting suggest that CPM can improve rehabilitation when postoperative mobility is restricted. However, current postoperative rehabilitation protocols are considerably different than when the largest body of evidence was collected, making it difficult to apply available evidence to the present situation. Recent literature suggests that institutional and home use of CPM has minimal benefit when combined with standard physical therapy after total knee arthroplasty (TKA). For patients who are unable to participate in standard physical therapy regimens, CPM remains an alternative physical therapy modality. Therefore, the use of CPM in the home setting may be considered medically necessary after TKA as an adjunct to physical therapy under conditions of low postoperative mobility or inability to comply with rehabilitation exercises, this may include patients with complex regional pain syndrome (reflex sympathetic dystrophy); extensive arthrofibrosis or tendon fibrosis; or physical, mental or behavioral inability to participate in active physical therapy. CPM may also be considered medically necessary for patients in the non-weight bearing period following intra-articular cartilage repair procedures of the knee.
For joints other than the knee, there has been interest in the use of CPM in other weight bearing joints such as hip, ankle and metatarsals and non-weight bearing joints including the shoulder, elbow, metacarpals and interphalangeal joints. The use of CPM is also being explored in stroke and burn patients. Based on the available published peer reviewed literature, the literature does not support the use of CPM postoperatively as adjunct to physical therapy for any joint other than the knee. Therefore, the use of CPM for joints other than the knee has not been medically proven to be effective in improving health outcomes and is considered not medically necessary.
If the CPM device is determined to be medically necessary, the CPM is payable only as rental equipment for 30 days following surgery.
Continuous Passive Motion (CPM) devices in the home setting may be considered medically necessary in the following situations, when the device is initiated within the 48-hours following surgery:
- Total knee arthroplasty (TKA) or total knee arthroplasty (TKA) revision
- Open reduction and internal fixation of tibial plateau or distal femur fractures involving the knee joint
- Knee arthrofibrosis occurring after Total Knee Arthroplasty (TKA) or total knee arthroplasty (TKA) and requiring manipulation under general anesthesia.
- Post operative rehabilitation after ACL reconstruction
Continuous Passive Motion (CPM) devices in the home setting 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
All other uses for the Continuous Passive Motion (CPM) device in the home setting are considered not medically necessary including but not limited to the following circumstances, because the available peer reviewed literature does not support their use post-peratively for any other joint:
- For any joint other than the knee
- For any condition of the knee other than those described above
Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis codes.
- E0935 Continuous passive motion exercise device for use on knee only
- E0936 Continuous passive motion exercise device for use other than knee
- 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].
- 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.
- Lobb R, Tumilty S, Claydon LS. A review of systematic reviews on anterior cruciate ligament reconstruction rehabilitation. Phys Ther Sport. 2012 Nov;13(4):270-8.
- 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 Oct;4(10):719-25.
- Kim YS, Chung SW, Kim JY, Ok JH, Part I, Oh JH. Is early passive motion exercise necessary after arthroscopic rotator cuff repair? Am J Sports Med. 2012 Apr;40(4):815-21.
- Maniar RN, Baviskar JV, Singhi T, RAthi SS. To use or not to use continuous passive motion post-total knee arthroplasty presenting functional assessment results in early recovery. J Arthroplasty. 2012 Feb;27(2):193-200.
- New England Journal of Medicine. Anterior Cruciate Ligament Tear. Kurt P. Spindler, M.D., and Rick W. Wright, M.D. November 13, 2008.
- ECRI. Hotline Response. Continuous Passive Motion Devices for Aiding Recovery Following Orthopedic Surgery. December 2012.
- Medicare National Coverage Determinations-Durable Medical Equipment Reference List (280.1). Manual 100-3.
- UpToDate. Total Knee Arthroplasty. Gregory M. Martin, M.D., Thomas S. Thorhill, M.D., Jeffery N. Katz, M.D., MSc. Topic Last updated August 4, 2015 www.uptodate.com
- Madeleine Denis, et. al. Effectiveness of Continuous Passive Range of Motion and Conventional Physical Therapy after Total Knee Arthroplasty: A Randomized Clinical Trial. Journal of the American Physical Therapy Association. February 2006. Also available at ptjournal.apta.org. Accessed September 19, 2014
- Medscape. Effectiveness of Prolonged Use of Continuous Passive Motion (CPM), as an Adjunct to Physiotherapy, After Total Knee Arthorplasty. www.medscape.com
- Medscape. Total Joint Replacement Rehabilitation. Updated March 19, 2014. http:// emedicine.medscape.com/article/320061-overview
- Orthopedicstoday. Continuous Passive Motion Offers no Benefits After Intra-Articular Fracture Treatment. August 7, 2014.www.healio.com
- Austin D. Hill, M.D., MPH, et. al. Use of Continuous Passive Motion in the Postoperative Treatment of Intra-Articular Knee Fractures. The Journal of Bone and Joint Surgery, July 16, 2014, volume 96, number 4, pp e118.doi
- Orthopedicstoday. The Still Knee: A Frustrating, Post TKA Challenge. May 2008. www.healio.com
- Healthline. Arthrofribrosis After Knee Replacement, medically reviewed by George Krucik, M.D., Published April 30, 2012. www.healthline.com
- UpToDate. Ryan P. Friedberg, M.D.. Patient Information: Anterior Cruciate Ligament Injury (Beyond the Basics). Topic Last Updated November 27, 2013. www.uptodate.com
- Medscape. Osteochondritis Dissecans. Updated May 1, 2014. http://emedicine.medscape.com/article/1253074-overview
- Harvey LA, Brosseau L. Herbert RD. Continuous Passive Motion After Knee Replacement Surgery. Conchrane Database Systemic Reviews 2014. Also, available at www.ncbi.nlm.nih.gov/pubmedhealth/PMH0012655
- ECRI. Hotline Response. Continuous Passive Motion Therapy for In-Hospital Rehabilitation after Knee Surgery, June 2015. Also available at www.ecri.org
- American Academy Orthopedic Surgeons (AAOS), Orthoinfo Distal Femur (Thighbone) Fractures of the Knee. Also available at http://orthoinfo.aaos.org
- America Academy of Orthopedic Surgeons (AAOS). Orthoinfo Total Knee Replacement. Also available at http://orthoinfo.aaos.org
- MedScape. Tibial Plateau Fractures Treatment and Management. Updated October 2014. Also available at http://emedicine.medscape.com
- Howard Jennifer, Mattacola Carl, 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.
- Husain Adeel, Stedman Roman, Nelson Charles, Evaluation and Management of the Stiff TKA. International Congress of Joint Reconstruction. Also available at http://icjr.net/article_96_knee_stiffness.htm
- Fazalare Joseph, Griesser Michael, et. al. The Use of Continuous Passive Motion Following Knee Cartilage Defect Surgery: A Systemic Review. Orthopedics December 2010 Volume 33 Issue 12. Also available at www.healio.com
- UpToDate. Complications of Total Arthroplasty, Gregory M. Martin, M.D., Thomas S. Thornhill, M.D., Jeffrey N. Katz, M.D., MSc, Topic last updated August 25, 2014. Also available at www.uptodate.com
Date Reason Action
December 2010 Annual review Policy renewed
December 2011 Annual review Policy renewed
December 2012 Annual review Policy renewed
October 2013 Annual review Policy renewed
October 2014 Annual review Policy revised
September 2015 Annual review Policy revised
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 © 2012 American Medical Association. All Rights Reserved.