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Cooling devices use chilled water to decrease the local temperature of tissue. 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, eg, after orthopedic surgical procedures.
Cold and/or compression therapy following surgery, or musculoskeletal and soft tissue injury has long been accepted in the medical field as an effective tool for reducing inflammation, pain, and swelling. Ice packs and various bandages and wraps are commonly used. 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.
The CryoCuff® and the Polar Care Cub devices are examples of passive cooling devices. The CryoCuff® device consists of an insulated container filled with iced water that is attached to a compressive cuff. When the container is raised, the water fills and pressurizes the cuff. The amount of pressure is proportional to the height of the container. When body heat warms the water, the cooler is lowered and the water drains out. The cooler is then raised above the affected limb, and cold water refills the compressive cuff. The Polar Care Cub unit consists of pads held in place with elastic straps, which may also provide compression. The pads are attached to a built-in hand pump that circulates the water through the pads at the same time as increasing the compression around the joint.
In active cooling devices, a motorized pump circulates chilled water and may also provide pneumatic compression. For example, the AutoChill® device, which may be used in conjunction with a CryoCuff, consists of a pump that automatically exchanges water from the cuff to the cooler, eliminating the need for manual water recycling. The Hot/Ice Thermal Blanket is another example of an active cooling device. It consists of 2 rubber pads connected by a rubber hose to the main cooling unit. Fluid is circulated via the hose through the thermal blankets. The temperature of the fluid is controlled by the main unit and can be either hot or cold. The Game Ready™ Accelerated Recovery System is an example of an active cooling device combined with a pneumatic component. The system consists of various soft wraps and a computer controlled control unit to circulate the water through the wraps and provide intermittent pneumatic compression. 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). CTM™ 5000 and cTreatment are computer-controlled devices that provide cooling at a specific (11°C) and continuous temperature.
POLICYActive and passive cooling devices are considered not medically necessary.
Combination active cooling and compression (cryopneumatic) devices are considered investigational.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY2/2001: Approved by Medical Policy Advisory Committee (MPAC), Code Reference section completed, HCPCS E0218 added
5/2/2002: Type of Service and Place of Service deleted
8/16/2005: Policy title "Polar Care" renamed "Cooling Devices," Description and Policy sections revised to be consistent with BCBSA policy # 1.01.26, Code Reference section updated, HCPCS E0236 added
4/25/2008: Policy reviewed, no changes
12/10/2009: Policy Exclusions revised to include FEP verbiage, HCPCS code E1399 added to Non-Covered Codes Table.
05/17/2011: Policy reviewed; no changes to policy statement. Removed outdated references from the Sources section.
03/02/2012: Policy reviewed. "Used in the Outpatient Setting" added to the policy title.
05/08/2013: Policy description updated. Added the following policy statement: Combination active cooling and compression (cryopneumatic) devices are considered investigational. Deleted the Federal Employee Program (FEP) policy exception as this device is also considered not medically necessary for FEP members.
06/05/2014: Policy reviewed; description updated. Policy statement unchanged.
07/13/2015: Code Reference section updated for ICD-10.
09/10/2015: Policy description updated regarding devices. Policy statements unchanged. Policy guidelines section updated to add investigative definition.
SOURCE(S)Blue Cross Blue Shield Association policy # 1.01.26
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.