BlueCross BlueShield of Tennessee Medical Policy Manual

Continuous Passive Motion (CPM) Device in the Home Setting

Does not apply to Medicare Advantage

DESCRIPTION

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 as an adjunct to physical therapy in the home setting. 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 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 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.

POLICY

MEDICAL APPROPRIATENESS

IMPORTANT REMINDERS

Does not apply to Medicare Advantage.

SOURCES

American Academy of Orthopaedic Surgeons. (2015). Surgical management of osteoarthritis of the knee; evidence based clinical practice guideline. Retrieved March 28, 2017 from ebm@aaos.org.

BlueCross BlueShield Association. Medical Policy Reference Manual. (5:2017). Continuous Passive Motion in the Home Setting (1.01.10). Retrieved March 12, 2018 from BlueWeb. (46 articles and/or guidelines reviewed)

Boese, C.K., Weis, M., Phillips, T., Lawton-Peters, S., Gallo, T., & Centeno, L. (2014). The efficacy of continuous passive motion after total knee arthroplasty: a comparison of three protocols. Journal of Arthroplasty, 29 (6), 1158-1162. Abstract retrieved March 12, 2018 from PubMed database.

Centers for Medicare & Medicaid Services. CMS.gov. National Coverage Determination (NCD) for Durable Medical Equipment Reference List (280.1).  Retrieved June 8, 2016 from https://www.cms.gov.

Chaudhry, H. and Bhandari, M. (2015). Cochrane in CORR1: Continuous passive motion following total knee arthroplasty in people with arthritis (review). Clinical Orthopaedics and Related Research, 473, 3348–3354. (Level 1 evidence)

Holschen, M., & Lobenhoffer, P. (2014). Treatment of extension contracture of the knee by quadriceps plasty. Operative Orthopädie und Traumatologie, 26 (4) 353-360. Abstract retrieved June 9, 2016 from PubMed database.

Nikolaou, V.S., Chytas, D., & Babis, G.C. (2014). Common controversies in total knee replacement surgery: current evidence. World Journal of Orthopedics, 5 (4), 460-468. (Level 2 evidence)

White, N.T., Delitto, A., Manal, T.J., & Miller, S. (2015). The American Physical Therapy Association’s top five choosing wisely recommendations. Physical Therapy, 95 (1), 9-24. (Level 2 evidence)

Winifred S. Hayes, Inc. Medical Technology Directory. (2013, March; last update search January 2017). Continuous passive motion for the treatment of joint contractures of the extremities. Retrieved March 28, 2017 from www.Hayesinc.com/subscribers. (76 articles and/or guidelines reviewed)

ORIGINAL EFFECTIVE DATE:  11/1986    

MOST RECENT REVIEW DATE:  4/12/2018

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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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