DESCRIPTION
The restoration of joint range of motion following surgery or trauma is dependent upon rehabilitation. Delay in rehabilitation may subsequently result in poor joint function or immobility. Passive motion, a treatment component of joint rehabilitation, may be performed by a physical therapist or accomplished with a continuous passive motion (CPM) device. To some extent, CPM devices and physical therapists are an interchangeable means of delivering passive motion. The preference for one or the other mode of delivery may be determined by considerations related to the organization of services or resource allocation (e.g., staffing, timing of discharge, access to physical therapy). Such use of a continuous passive motion device as a substitute for a physical therapist delivering passive motion should be distinguished from use of the device as an adjunct to physical therapy. As an adjunct to physical therapy, the objective is to increase the duration and intensity of passive motion in order to achieve outcomes superior to that achieved by conventional physical therapy programs.
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.
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
The continuous passive motion (CPM) device when initiated during the immediate postoperative period is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
The continuous passive motion (CPM) device, for all other uses, is considered investigational.
MEDICAL APPROPRIATENESS
Continuous passive motion (CPM) device when initiated during the immediate postoperative period is considered medically appropriate if ALL the following are met:
Use of the CPM device is initiated within 48 hours after surgery
The device is used after ANY ONE of the following:
Total knee arthroplasty (TKA)
Reconstruction (open or arthroscopic repair) of the anterior cruciate ligament (ACL) of the knee
ADDITIONAL INFORMATION
The current published literature shows that treating post surgical joints with the continuous passive motion device has the same long term outcome as treating them with early physical therapy and weight bearing.
Well-designed and randomized controlled trials published in peer-reviewed literature regarding the use of the continuous passive motion (CPM) device, for conditions other than those considered medically necessary above, are not available at this time.
Examples of when the CPM device is considered investigational include:
For treatment of injury or as postoperative care of the articular tissues in the shoulder, elbow, or hand, and where passive motion is considered an appropriate form of therapy, and the individual is motivated and able to use the CPM device correctly if therapy is to be performed at home
For rehabilitation after periosteal transplantation for traumatic full-thickness cartilage defects of the patella
For rehabilitation after injury or surgery on other synovial joints, such as the TMJ
For treatment of degenerative joint diseases, such as rheumatoid arthritis
For treatment of acute, chronic or surgically related lumbar injuries
For all other uses (other than those uses listed under Medical Appropriateness above).
BCBST recognizes the use of the continuous passive motion (CPM) device when used for up to 21 days immediately following medically appropriate surgery (as listed under Medical Appropriateness above).
Hospitalization is not medically justified solely for the use of the continuous passive motion (CPM) device.
SOURCES
Bennett, L. A., Brearley, S. C., Hart, J. A., & Bailey, M. J. (2005). A comparison of 2 continuous passive motion protocols after total knee arthroplasty: A controlled and randomized study. The Journal of Arthroplasty, 20 (2), 225-233. (Level 2 Evidence)
BlueCross BlueShield Association. Medical Policy Reference Manual. (11:2008). Continuous passive motion (CPM) in the home setting (1.01.10). Retrieved February 16, 2009 from BlueWeb.
Brosseau, L., Milne, S., Wells, G., Tugwell, P., Robinson, V., Casimiro, L., et al. (2004). Efficacy of continuous passive motion following total knee arthroplasty: A metaanalysis. The Journal of Rheumatology, 31 (11), 2251-2264. (Level 4 Evidence)
Complete Guide To Medicare Coverage Issues [Computer Software]. (2008, November). Durable medical equipment reference list (NCD 280.1, p. 2-204 – p. 2-209). The Ingenix Complete Guide to Medicare Coverage Issues.
Denis, M., Moffet, H., Caron, F., Ouellet, D., Paquet, J., & Nolet, L. (2006). Effectiveness of continuous passive motion and conventional physical therapy after total knee arthroplasty: A randomized clinical trial. Physical Therapy, 86, (2). 174-185. (Level 2 Evidence)
Fuchs, S., Heyse, T., Rudofsky, G., Gosheger, G., & Chylarecki, C. (2005). Continuous passive motion in the prevention of deep-vein thrombosis: A randomised comparison in trauma patients. Journal of Bone and Joint Surgery, 87 (8), 1117-1122. (Level 4 Evidence)
Hayes. Medical Technology Directory. (2005, July). Mechanical stretching devices and continuous passive motion for joints of the extremities. Retrieved February 16, 2009 from http://www.Hayesinc.com/subscribers. (78 articles and/or guidelines reviewed)
Lenssen, A. F., Crijns, Y. H., Waltje, E. M., Roox, G. M., van SteynRuud, M., J., Geesink, R. J, et al. (2006). Effectiveness of prolonged use of continuous passive motion (CPM) as an adjunct to physiotherapy following total knee arthroplasty: Design of a randomised controlled trial. BMC Musculoskeletal Disorders, 7 (15), 1-10. (Level 2 Evidence)
Milne S, Brosseau L, Robinson V, Noel MJ, Davis J, Drouin H, Wells G, Tugwell P. Continuous passive motion following total knee arthroplasty. The Cochrane Database of Systematic Reviews 2003, Issue 2. Art. No.: CD004260. DOI: 10.1002/14651858.CD004260. (46 articles and/or guidelines reviewed)
U. S. Department of Health & Human Services. Centers for Medicare and Medicaid Services. LMRPs/LCDs for CIGNA Government Services. (2007, June). Article for continuous passive motion (A4265). Retrieved February 16, 2009 from http://www.cms.hhs.gov/mcd/viewarticle.asp?article_id=4265&article_version=4&show=all.
ORIGINAL EFFECTIVE DATE: 11/1986
MOST RECENT REVIEW DATE: 4/9/2009
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.
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