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Medical Policy: 01.01.04
Original Effective Date: December 1993
Reviewed: January 2008
Revised: August 2004
This policy applies to all products unless specific contract
limitations, exclusions or exceptions apply. Please refer to the member's coverage
manual for benefit availability. Managed care guidelines related to referral authorization,
and precertification of inpatient hospitalization, home health, home infusion and
hospice services apply.
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.
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
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, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- HCPCS code E0935 Continuous passive motion exercise device for use on knee only
- HCPCS code 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.
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New information or technology that would be relevant for Wellmark to consider when this policy is next reviewed may be submitted to:
Wellmark Blue Cross and Blue Shield
Medical Policy Analyst
Station 304
636 Grand Ave
Des Moines, Iowa 50309
*Current Procedural Terminology © 2008 American Medical Association. All Rights Reserved.
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.
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