This policy does not address the use of conventional ice packs. 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.
There are a variety of cooling devices available, ranging from gravity-fed devices that are manually filled with iced water, to motorized units that both cool and circulate the chilled water. These devices are typically used when ice packs would normally be applied, e.g., after orthopedic surgical procedures. In addition, a variety of continuous cooling devices are commercially available and can be broadly subdivided into those providing manually operated passive cold therapy and those providing active cold therapy using a mechanical device.
In passive or non-circulating cooling devices an insulated container filled with iced water is attached to a compressive cuff. When the container is raised, the water fills and pressurizes the cuff by gravity or built-in hand pump. Examples of this type of device are the CryoCuff®, Iceman Cold Therapy, and Polar Care® Cub.
In active or circulating cooling devices, a motorized pump operated by battery or electricity circulates chilled water and may also provide pneumatic compression. Examples of this type of device are the Aircast AutoChill® Cold Therapy System, Arctic Ice Therapy System, OPTI-ICE™ Cold Therapy System, Polar Care® 500 and Hot/Ice Thermal Blanket. The Game Ready™ Accelerated Recovery System and Polar Care® 300 are circulating cooling devices combined with a pneumatic component. The Hilotherm® Clinic circulates cooled water through preshaped thermoplastic polyurethane facial masks for use after different types of facial surgery. ThermaZone® provides thermal therapy with pads specific to various joints as well as different areas of the head (front, sides, back, eyes).
Active (circulating) and passive (non-circulating) cooling devices used in the outpatient setting are considered not medically necessary.
Combination active cooling and compression (cryopneumatic) devices used in the outpatient setting are considered investigational.
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.
There is insufficient evidence in published, peer-reviewed scientific literature to conclude that the application of combination active cooling and compression (cryopneumatic) devices in the outpatient setting have clinical benefits over the conventional application of ice packs and bandages. Well-designed studies are needed to demonstrate that these devices provide additional clinical benefits.
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. (Level 2 evidence)
Alfuth, M., Strietzel, M., Vogler, T., Rosenbaum, D., and Liem. D. (2016, July) Cold versus cold compression therapy after shoulder arthroscopy: a prospective randomized clinical trial. Knee Surgery, Sports Traumatology, Arthroscopy, 24(7), 2209-15. Abstract retrieved January 10, 2018 from PubMed database.
American Academy of Orthopaedic Surgeons (2015) Surgical management of osteoarthritis of the knee, evidence based clinical practice guideline. Retrieved January 10, 2018 from http://www.aaos.org.
BlueCross BlueShield Association. Evidence Positioning System. (3:2018). Cooling devices used in the outpatient setting (1.01.26). Retrieved November 19, 2018 from http://www.evidencepositioningsystem.com . (24 articles and/or guidelines reviewed)
CMS.gov: Center for Medicare & Medicaid Services. CGS Administrators, LLC (2017, January). Cold Therapy. (LCD ID: L33735) Retrieved November 19, 2018 from https://www.cms.gov.
Fullam, K., Caulfield, B., Coughlan, G. F., McGroarty, M., & Delahunt, E. (2015). Dynamic postural-stability deficits after cryotherapy to the ankle joint. Journal of Athletic Training, 50 (9), 893-904. (Level 4 evidence)
Su, E. P., Perna, M., Boettner, F., Mayman, D. J., Gerlinger, T., Barsoum, W., et al. (2012). A prospective, multi-center, randomised trial to evaluate the efficacy of a cryopneumatic device on total knee arthroplasty recovery. Journal of Bone & Joint Surgery (British Volume), 94 (11, Suppl A), 153-156. Abstract retrieved January 9, 2017 from PubMed database.
U. S. Food and Drug Administration. (1993, April). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K925677 (AutoChil®). Retrieved October 12, 2010 from http://www.accessdata.fda.gov.
U. S. Food and Drug Administration. (1996, August). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K961855 (PolarCare® 500). Retrieved January 9, 2017 from http://www.accessdata.fda.gov.
U. S. Food and Drug Administration. (2007, June). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K071050 (CoolSystems). Retrieved January 9, 2017 from http://www.accessdata.fda.gov.
Winifred S. Hayes, Inc. Health Technology Brief (2013, December, last update search November 2015) Cold compression therapy for orthopedic conditions. Retrieved January 10, 2018 from www.hayesinc.com.
ORIGINAL EFFECTIVE DATE: 8/11/2007
MOST RECENT REVIEW DATE: 2/14/2019
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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