Continuous Passive Motion (CPM) Device in the Home Setting
Does not apply to Medicare Advantage
DESCRIPTION
Physical therapy 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 (Continuous Passive Motion) devices have also been used. Continuous passive motion 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.
The CPM device continuously moves the affected joint (e.g., flexion/extension) without assistance on a 24-hour basis. The CPM device is held in place across the affected joint by Velcro straps. An electrical power unit is used to set the variable range of motion (ROM) and speed. The initial settings for ROM are based on the level of comfort of the individual receiving therapy and other factors that are assessed intraoperatively. The initial settings are made by a physical therapist or by other health professionals familiar with the device. The ROM is increased 3-5 degrees per day as tolerated. The speed and range of motion can be varied depending on joint stability. An emergency stop switch immediately halts the device if necessary. The use of the devices may be initiated in the immediate postoperative period and then continued at home for a variable period of time.
A wide variety of CPM devices are available for rehabilitation of specific joints. CPM devices are available for synovial joints (hip, knee, ankle, shoulder, elbow, and wrist) following surgery or trauma (including fracture, infection, etc.).
POLICY
Use of a continuous passive motion (CPM) device in the home setting is considered medically necessary as an adjunct to physical therapy if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Use of a continuous passive motion (CPM) device in the home setting for all other conditions is considered not medically necessary.
MEDICAL APPROPRIATENESS
Continuous passive motion (CPM) in the home setting as an adjunct to physical therapy is considered medically appropriate if ANY ONE of the following criteria are met:
Following either total knee arthroplasty (TKA) / TKA revision under conditions of low postoperative mobility or inability to comply with rehabilitation exercises. (e.g., individuals 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)
Intra-articular cartilage repair procedure of the knee (e.g., microfracture, osteochondral grafting, autologous chondrocyte implantation, treatment of osteochondritis dissecans, repair of tibial plateau fractures) during the non-weight-bearing rehabilitation period
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.
Does not apply to Medicare Advantage.
SOURCES
BlueCross BlueShield Association. Medical Policy Reference Manual. (7:2010). Continuous passive motion (CPM) in the home setting (1.01.10). Retrieved December 7, 2010 from BlueWeb. (29 articles and/or guidelines reviewed)
Complete Guide to Medicare Coverage Issues [Computer software]. (2010, April). Durable medical equipment reference list (NDC 280.1, p. 2-205 - 2-210). Ingenix.
Dundar, U., Toktas, H., Cakir T et al. (2009). Continuous passive motion provides good pain control in patients with adhesive capsulitis. International Journal of Rehabilitation Research, 32 (3), 193-198.
Lenssen, T. A., van Steyn, M. J., Crijns, Y. H., Waltjé, E. M., Roox, G. M., Geesink, R. J., et al. (2008). Effectiveness of prolonged use of continuous passive motion (CPM), as an adjunct to physiotherapy, after total knee arthroplasty. BMC Musculoskelet Disorders, 9:60.
ORIGINAL EFFECTIVE DATE: 11/1986
MOST RECENT REVIEW DATE: 4/14/2011
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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.
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