DESCRIPTION
Ice packs and various cooling bandages and wraps are commonly used following surgery or musculoskeletal and soft tissue injury. These types of cooling therapy are accepted and effective tools used to reduce inflammation, pain and swelling. This policy does not address the use of conventional ice packs.
Manufactured cooling devices are either active or passive:
Active cooling devices (e.g., AutoChill® system, Game Ready™ Accelerated Recovery System, Iceman Cold Therapy, Nanotherm™, OPTI-ICE™ Cold Therapy System, Polar Care 500, Polar Care 300) are designed to provide a steady low temperature with a motorized pump circulating cold water. An active cooling device may also provide pneumatic compression.
Passive cooling devices (e.g., ArcticFlow Cold therapy system, Cryocuff®, Polar Care Cub) are designed to recirculate cool water by gravity.
POLICY
Active and passive cooling devices used in the outpatient setting are considered not medically necessary.
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
ADDITIONAL INFORMATION
There is insufficient evidence in published, peer-reviewed scientific literature to conclude that the application of active and passive cooling devices in the outpatient setting have clinical benefits over the conventional application of ice packs. Well-designed studies and randomized, controlled clinical trials are needed to demonstrate that these devices provide additional clinical benefits.
SOURCES
Adie, S., Naylor, J. M., & Harris, I. A. (2010). Cryotherapy after total knee arthroplasty. A systematic review and meta-analysis of randomized controlled trials. The Journal of Arthroplasty, 25 (5), 709-715.
Bleakley, C. M., O’Connor, S., Tully, M. A., Rocke, L. G., Macauley, D. C., & McDonough, S. M. (2007). The PRICE study (Protection Rest Ice Compression Elevation): Design of a randomised controlled trial comparing standard versus cryokinetic ice applications in the management of acute ankle sprain [ISRCTN13903946]. BMC Musculoskeletal Disorders, 8, 125. (Level 2 Evidence - Independent study)
Block, J. E. (2010). Cold and compression in the management of musculoskeletal injuries and orthopedic operative producedures: A narrative review. Open Access Journal of Sports Medicine, 1, 105-113.
BlueCross BlueShield Association. Medical Policy Reference Manual. (11:2009). Cooling devices used in the outpatient setting (1.01.26). Retrieved October 11, 2010 from BlueWeb. (16 articles and/or guidelines reviewed)
Denegar, C. R., Dougherty, D. R., Friedman, J. E., Schimizzi, M. E., Clark, J. E., Comstock, B. A., et al. Preferences for heat, cold, or contrast in patients with knee osteoarthritis affect treatment response. Clinical Interventions in Aging, 5, 199-206.
McGuire, D. A., & Hendricks, S. D. (2006). Incidences of frostbite in arthroscopic knee surgery postoperative cryotherapy rehabilitation. Arthroscopy, 22 (10), 1141e1-1141e6.
U. S. Department of Health & Human Services. Center for Medicare & Medicaid Services. LCD s for CIGNA Government Services. (2008, March). LCD for cold therapy (L11552). Retrieved October 15, 2010 from http://www.cms.gov/mcd/viewlcd.asp?lcd_id=11552&lcd_version=17&show=all.
U. S. Food and Drug Administration. (1993, April). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K925677. Retrieved October 12, 2010 from http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=96101.
U. S. Food and Drug Administration. (2006, August). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K061866. Retrieved October 12, 2010 from http://www.accessdata.fda.gov/cdrh_docs/pdf6/K061866.pdf.
U. S. Food and Drug Administration. (2010, April). Center for Devices and Radiological Health. Code of Federal Regulations: Title 21: Volume 8: 21CFR890.5720: Part 890 Physical Medicine Devices: Section 890.5720. Water circulating hot or cold pack. Retrieved October 14, 2010 from http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?FR=890.5720.
ORIGINAL EFFECTIVE DATE: 8/11/2007
MOST RECENT REVIEW DATE: 11/11/2010
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
This document has been classified as public information.