Continuous Passive Motion (CPM) Devices in the Home Setting

» Summary» Procedure Codes
» Description» Selected References
» Prior Approval» Policy History
» Policy
 

Medical Policy: 01.01.04 
Original Effective Date: December 1993 
Reviewed: September 2015 
Revised: March 2016 


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: 

 

 

Note: The administration of CPM devices of the knee in the home setting in lieu of or in conjunction with physical therapy will be administered beginning April 26, 2016.    

 

 

Continuous passive motion (CPM) devices are used to keep a joint in motion without patient assistance. CPM is being evaluated for treatment and postsurgical rehabilitation of the upper- and lower-limb joints and for a variety of musculoskeletal conditions.

 

The device moves the joint (e.g., flexion/extension), without patient assistance, continuously for extended periods of time (i.e., up to 24 hours/day). An electrical power unit is used to set the variable range of motion (ROM) and speed. The initial settings for ROM are based on a patient’s level of comfort and other factors that are assessed intraoperatively. The ROM is increased by 3 to 5 degrees per day, as tolerated. The speed and ROM can be varied, depending on joint stability. The use of the devices may be initiated in the immediate postoperative period and then continued at home for a variable period of time.

 

Physical therapy (PT) of joints following surgery focuses both on passive motion to restore mobility and active exercises to restore strength. While passive motion can be administered by a therapist, CPM devices have also been used. Continuous passive motion (CPM) is thought to improve recovery by stimulating the healing of articular tissues and circulation of synovial fluid; reducing local edema; and preventing adhesions, joint stiffness or contractures, or cartilage degeneration. CPM has been most thoroughly investigated in the knee, particularly after total knee arthroplasty (TKA) or ligamentous or cartilage repair, but its acceptance in the knee joint has created interest in extrapolating this experience to other weight-bearing joints (i.e., hip, ankle, metatarsals) and non-weight-bearing joints (i.e., shoulder, elbow, metacarpals, interphalangeal joints). Use of CPM in stroke and burn patients is also being explored. 

 

Most research on CPM has been as a postoperative treatment for total knee arthroplasty (TKA). Numerous randomized controlled trials (RCTs) have been performed comparing CPM as an adjunct to physical therapy (PT) for patients undergoing TKA. Early trials generally used CPM in the inpatient setting and are less relevant to today’s practice patterns of short hospital stays followed by outpatient rehabilitation. Current postoperative rehabilitation protocols are considerably different than when the largest body of evidence was collected, making it difficult to apply the available evidence to the present situation.

 

Based on review of the evidence on total knee replacement that includes several RCTs and a large Cochrane review with a body of evidence extending back to the 1980’s. The systematic reviews identified described limited clinical usefulness for CPM in rehabilitation after knee surgery and described the quality of the evidence as low. The Cochrane review by Harvey et. al. 2014 included 24 RCTs with 1,445 patients and described the effects of CPM on outcomes after total knee replacement such as range of motion, function, pain and quality of life as “not clinically important.”

 

With respect to reducing deep-venous thrombosis after total knee replacement, the systemic review by He et. al. concluded the evidence is insufficient to determine a benefit from using CPM. This review included 11 RCTs with 808 patients. The results of the meta-analysis showed no evidence that CPM had any effect on preventing venous thrombosis after total knee replacement.

 

Continuous passive motion (CPM) is also commonly used postoperatively following articular cartilage repair surgery. Unfortunately, the clinical evidence to support the use of CPM is lacking (only 4 clinical studies) and despite the overwhelming abundance of basic science support and the common clinical practice of the use of CPM postoperatively the study results were heterogeneous and were considered low-quality evidence of any benefit from CPM when used after these procedures. Further randomized controlled trials are needed comparing the use of CPM in patients undergoing the same cartilage restoration procedure with patients treated without CPM and only active ROM which would provide high-quality clinical outcome research on which to base postoperative decisions. Also, based on the literature changes in clinical practice have occurred over time which is allowing weight bearing as tolerated immediately following cartilage repair with a gradual increase to full weight bearing at 8 weeks which has been reported to safely improve pain, function, and activity compared to more conservative progression with no increase of complications as of 3 months post operation. Studies also support the need for some degree of compressive loading in addition to joint motion for successful cartilage healing.

 

The literature suggests that institutional and home use of CPM has minimal benefit alone or when combined with standard PT after TKA, TKA revision or intra-articular cartilage repair. For patients who are unable to participate in standard PT regimens (due to low postoperative mobility or inability to comply with rehabilitation exercises), CPM remains as an alternative PT modality.  

 

For use of CPM in joints other than the knee, there is limited published evidence. In addition, clinical support was limited for these indications. Three small RCTs of CPM post‒rotator cuff surgery have been identified in the literature. There is some evidence that use of CPM following rotator cuff repair of the shoulder improves short-term pain and range of motion (ROM); however, this is not high quality evidence, and the small differences in outcomes may not be clinically important. Two of these trials report short-term improvements in ROM for patients undergoing CPM, and 1 reports a short-term reduction in pain. None of the trials report long-term improvements, nor are there any reported benefits in functional status or quality of life. Therefore, the clinical significance of the short-term improvements reported is uncertain. In addition, there is uncertainty about the optimal PT regimen post‒shoulder surgery such that the optimal comparison for CPM is not clear. Larger RCTs with longer follow-up are required to determine whether CPM following rotator cuff surgery results in clinically meaningful improvements in health outcomes. The available evidence is insufficient to permit conclusions concerning the effect of this technology on health outcomes for all other joints.

 

Summary

Based on review of the medical literature the literature reports an improvement in ROM for patients receiving CPM, but these improvements are short term, of small magnitude, and of uncertain clinical significance. No RCTs have reported clinically meaningful improvements in important clinical outcomes such as functional status and/or quality of life compared to those who used CPM in adjunct to physical therapy following TKA, TKA revision or articular cartilage repair surgery.

 

The literature suggests that institutional and home use of CPM has minimal benefit alone or when combined with standard PT after TKA, TKA revision or intra-articular cartilage repair. For patients who are unable to participate in standard PT regimens (due to low postoperative mobility or inability to comply with rehabilitation exercises), CPM remains as an alternative PT modality.

 

For use of CPM in joints other than the knee, there is limited published evidence. In addition, clinical support was limited for these indications. There may be some evidence that use of CPM may improve short term pain and range of motion, but these improvements are short term, of small magnitude, and of uncertain clinical significance. Larger RCTs with longer follow-up are required to determine whether the use of CPM in joints other than the knee shows clinically meaningful improvements in health outcomes. The available evidence is insufficient to permit conclusions concerning the effect of this technology on health outcomes for all other joints.

 

Practice Guidelines and Position Statements

American Academy of Orthopedic Surgeons (AAOS)

In 2015, the American Academy of Orthopedic Surgeons issued an evidence based clinical practice guideline for the surgical management of osteoarthritis of the knee which states: "Continuous Passive Motion: Strong evidence supports that CPM after knee arthroplasty (KA) does not improve outcomes.  Strength of recommendations: Strong Evidence."

 

Regulatory Status
CPM devices are considered class I devices by the FDA and are exempt from 510(k) requirements. This classification does not require submission of clinical data regarding efficacy but only notification of the FDA before marketing. 


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Prior Approval: 

 

Not applicable


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Policy: 

If the CPM device is determined to be medically necessary, the CPM is payable only as rental equipment for 30 days following surgery.

 

Medically Necessary

 

Use of continuous passive motion (CPM) device in the home setting may be considered medically necessary in the below situations as an alternative to physical therapy when the patient has 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):

  • Following total knee arthroplasty (TKA) or total knee arthroplasty (TKA) revision.
  • Following intra-articular cartilage repair procedures of the knee (e.g. microfracture, osteochondral grafting, autologous chondrocyte implantation, treatment of osteochondritis dissecans, repair of tibial plateau fractures, ACL reconstruction).  

The literature suggests that institutional and home use of CPM has minimal benefit alone or when combined with standard PT after TKA, TKA revision or intra-articular cartilage repair. For patients who are unable to participate in standard PT regimens (due to low postoperative mobility or inability to comply with rehabilitation exercises), CPM remains as an alternative PT modality

 

Not Medically Necessary

 

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:

  • For any joint other than the knee
  • For any condition of the knee other than those described above    

Based on review of the medical literature the literature reports an improvement in ROM for patients receiving CPM, but these improvements are short term, of small magnitude, and of uncertain clinical significance. No RCTs have reported clinically meaningful improvements in important clinical outcomes such as functional status and/or quality of life compared to those who didn’t use CPM or used CPM in adjunct to physical therapy. The available literature does not support their use postoperatively. Further randomized controlled trials are needed comparing the use of CPM in patients undergoing the same procedures with patients treated without CPM and only active ROM which would provide high-quality clinical outcome research on which to base postoperative decisions and therefore is considered not medically necessary.  
 
Duplicate habilitative therapy is considered not medically necessary. When individuals are receiving physical therapy the therapist should provide different treatments and not duplicate the same treatment (i.e. CPM provides ROM (range of motion) and physical therapy protocols also typically provide ROM treatment/services). 





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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 diagnosis 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 InstituteExternal Site; 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.
  • ECRIExternal Site. 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.
  • UpToDateExternal Site. 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.
  • 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
  • MedscapeExternal Site. Effectiveness of Prolonged Use of Continuous Passive Motion (CPM), as an Adjunct to Physiotherapy, After Total Knee Arthorplasty.
  • 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. HealioExternal Site
  • HealthlineExternal Site. Arthrofribrosis After Knee Replacement, medically reviewed by George Krucik, M.D., Published April 30, 2012.
  • UpToDateExternal Site. Ryan P. Friedberg, M.D.. Patient Information: Anterior Cruciate Ligament Injury (Beyond the Basics). Topic Last Updated November 27, 2013.
  • Medscape. Osteochondritis DissecansExternal Site. Updated May 1, 2014.
  • Harvey LA, Brosseau L. Herbert RD. Continuous Passive Motion After Knee Replacement Surgery. Conchrane Database Systemic Reviews 2014External Site.
  • ECRIExternal Site. Hotline Response. Continuous Passive Motion Therapy for In-Hospital Rehabilitation after Knee Surgery, June 2015.
  • American Academy Orthopedic SurgeonsExternal Site (AAOS), Orthoinfo Distal Femur (Thighbone) Fractures of the Knee.
  • American Academy Orthopedic SurgeonsExternal Site (AAOS). Orthoinfo Total Knee Replacement.
  • MedScapeExternal Site. Tibial Plateau Fractures Treatment and Management. Updated October 2014.
  • 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 TKAExternal Site. International Congress of Joint Reconstruction.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. HealioExternal Site
  • UpToDateExternal Site. 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.
  • Rogan S, Taymans J, Hirschmuller A, et. al. Effect of continuous passive motion for cartilage regenerative surgery – a systematic literature review. Z Orthop Unfall 2013 Oct;151(5):468-74. PMID 24129716
  • 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 Jun;29(6):1158-62. PMID 24412145
  • Harvey LA, Brosseau L, Herbert RD. Continuous passive motion following total knee arthroplasty in people with arthritis. Conchrane Database Syst Rev 2010 Mar 17;(3):CD004260. PMID 20238330
  • He ML, Xiao ZM, Lei M, et. al. Continuous passive motion for preventing venous thromboembolism after total knee arthroplasty. Cochrane Database Syst Rev 2014 Jul 29;7:CD008207. PMID 25069620
  • 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):277-83
  • Herbold JA, Bonistall K, Blackburn M, et. al. Arch Phys Med Rehabil 2014 Jul;95(7):1240-5. PMID 24685389
  • 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. PMID 22959052
  • 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 Jul 16;96(14)e118. PMID 25031380
  • Karnes JM, Harris JD, Griesser MJ, et. al. Continuous passive motion following cartilage surgery: does a common protocol exist? Phys Sportsmed 2013 Nov;41(4):53-63. PMID 24231597
  • 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 systemic review. Clin Rehabil 2011 Apr;25(4):291-302. PMID 20943710
  • 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 May;94 Suppl 1:S79-83. PMID 20383685
  • Dundar U, Toktas H, Cakir T, et. al. Continuous passive motion provides good pain control in patients with adhesive capsulitis. In J Rehabil Res 2009 Sep;32(3):193-8. PMID 19011582
  • Lynch D, Ferraro M, Krol J, et. al. Continuous passive motion improves shoulder joint integrity following stroke. Clin Rehabil 2005 Sep;19(6):594-9. PMID 16180594
  • 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 May-Jun;34(5):858-65. PMID 19362791
  • Schwartz DA, Chafetz R. Continous Passive Motion after tenolysis in hand therapy patients: a retrospective study. J Hand Ther 2008 Jul-Sep;21(3):261-6. PMID 18652971
  • Clinical Practice Guideline for the Surgical Management of Osteoarthritis of the knee. Adopted by the American Board of Orthopedic Surgeons Board of Directors 12.4.15. Also available at www.aaos.org

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Policy History: 

March 2016 - Interim Review, Policy Revised

September 2015 - Annual Review, Policy Revised

October 2014 - Annual Review, Policy Revised

October 2013 - Annual Review, Policy Renewed

December 2012 - Annual Review, Policy Renewed

December 2011 - Annual Review, Policy Renewed

December 2010 - 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 © 2012 American Medical Association. All Rights Reserved.

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  Medical Policy Analyst
  P.O. Box 9232
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