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Continuous passive motion (CPM) devices are available for synovial joints (hip, knee, ankle, shoulder, elbow, and wrist) following surgery or trauma (including fracture, infection, etc.).

The device moves the joint (e.g., flexion/extension), without patient assistance, continuously on a 24-hour basis. The 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 a patient's level of comfort and other factors that are assessed intraoperatively. These settings are made by a physical therapist or other health professional familiar with these devices. The ROM is increased by 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. The use of the devices may be initiated in the immediate postoperative period and then continued at home for a variable period of time.

Note: The policy only addresses CPM in the home setting.

• Under conditions of low postoperative mobility or inability to comply with rehabilitation exercises following a total knee arthroplasy (TKA) or TKA revision.  This may include patients 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.
• During the non-weight bearing rehabilitation period following intra-articular cartilage repair procedures of the knee (e.g., microfracture, osteochondral grafting, autologous chondrocyte implantation, treatment of osteochondritis dissecans, repair of tibial plateau fractures).

Use of CPM in the home setting for all other conditions is considered investigational.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

2/1997: Revisions approved by MPAC:

• Indications as an adjunct to physical therapy limited to total knee and elbow arthroplasty;
• Use of device limited to seven (7) days.

5/2000: Revisions approved by MPAC:

• Addition of ACL repair medically indications;
• Use for medically necessary indications extended to 14 days;
• Use in conjunction with conventional physical therapy considered medically necessary.

5/2001: Reviewed by MPAC; sources updated

2/15/2002: Investigational definition added

4/18/2002: Type of Service and Place of Service deleted

5/29/2002: Code Reference section updated, ICD-9 diagnosis codes 715.16, 715.18 deleted covered codes, non-covered codes table added, CPT code 97110 added non-covered codes, ICD-9 procedure code 93.38, 93.39 added non-covered codes

8/2002: Reviewed by MPAC; Use of the CPM device as a single treatment is not medically necessary

11/3/2004: Code Reference section updated, CPT code 24360-24363, 27407, 27409, 27447, 27486-27487 deleted covered codes, ICD-9 procedure code 81.45, 81.54, 81.55, 81.84 deleted covered codes, ICD-9 diagnosis code 715.16, 717.83 added covered codes, ICD-9 diagnosis code range 718.50-718.59, 718.80-718.89, 719.80-719.89 listed separately, non-covered codes table deleted, CPT code 97110 deleted non-covered codes, ICD-9 procedure code 93.38, 93.39 deleted non-covered codes

3/13/2006: Coding updated. HCPCS 2006 revisions added to policy

3/20/2006: Policy reviewed, no changes

12/27/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions

4/24/2007: Policy reviewed, no changes

1/5/2009: Policy reviewed, policy statement re-written to allow for CPM for the following, "During the non-weight bearing rehabilitation period following intra-articular cartilage repair procedures of the knee (e.g., microfracture, osteochondral grafting, autologous chondrocyte implantation, treatment of osteochondritis dissecans, repair of tibial plateau fractures)."  Elbow arthroplasty and ACL repairs removed from the medically necessary language. Day limit language has been removed.

06/23/2010:  Description section revised.  Code Reference section revised to add the following ICD-9 Diagnosis Codes: 170.7; 337.22; 714.0; 715.96; 716.16; 716.96; 717.0 - 717.9; 718.26; 718.36; 718.56;  718.76; 718.86; 730.06; 730.16; 730.26; 732.7 and V43.65  to the Covered Codes Table. A Non-Covered Codes Table was created and E0936 was moved to non-covered table based on policy statement.

08/11/2010: Policy reviewed; no changes.

08/03/2011: Policy reviewed. Policy statement unchanged. Deleted outdated references from the Sources section.

09/25/2012: Policy reviewed; no changes.

The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document. 

Covered Codes

This is not an all-inclusive list of non-covered procedure codes.

The code(s) listed below and ANY code not listed in the previous section are considered non-covered for this procedure.

Non-Covered Codes

Code Number	Description
CPT-4
ICD-9 Procedure
ICD-9 Diagnosis

HCPCS
E0936	Continuous passive motion exercise device for use other than knee (Moved to non-covered 06-23-2010)

 

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