Continuous Passive Motion (CPM) Device in the Home Setting
Does not apply to Medicare Advantage
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.
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 as an adjunct to physical therapy for all other conditions/ diseases (e.g. joints other than the knee) is considered investigational.
Continuous passive motion (CPM) is considered medically appropriate if ANY ONE of the following criteria are met:
In the home setting as an adjunct to physical therapy when ANY ONE of the following are met:
Low postoperative mobility or inability to comply with rehabilitation exercises following either total knee arthroplasty (TKA) or TKA revision (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
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
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
American Academy of Orthopaedic Surgeons. (2015). Surgical management of osteoarthritis of the knee; evidence based clinical practice guideline. Retrieved March 28, 2017 from: firstname.lastname@example.org.
BlueCross BlueShield Association. Evidence Positioning System. (3:2018). Continuous Passive Motion in the Home Setting (1.01.10). Retrieved December 17, 2018 from http://www.evidencepositioningsystem.com. (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)
Winifred S. Hayes, Inc. Medical Technology Directory. (2018, March). Continuous passive motion for knee indications. Retrieved December 17, 2018 from www.Hayesinc.com/subscribers. (35 articles and/or guidelines reviewed)
ORIGINAL EFFECTIVE DATE: 11/1986
MOST RECENT REVIEW DATE: 3/28/2019
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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