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DESCRIPTIONPhysical therapy of joints following surgery focuses both on passive motion to restore mobility and active exercises to restore strength. While passive motion can be administered by a therapist, continuous passive motion (CPM) devices have also been used. Continuous passive motion is thought to improve recovery by stimulating the healing of articular tissues and circulation of synovial fluid; reduce local edema; and prevent adhesions, joint stiffness or contractures, or cartilage degeneration. CPM has been most thoroughly investigated in the knee, particularly after total knee arthroplasty or ligamentous or cartilage repair, but its acceptance in the knee joint has created interest in extrapolating this experience to other weight-bearing joints (i.e., hip, ankle, metatarsals) and non-weight-bearing joints (i.e., shoulder, elbow, metacarpals, and interphalangeal joints). Use of CPM in stroke and burn patients is also being explored.
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.
POLICYUse of CPM in the home setting may be considered medically necessary as an adjunct to physical therapy in the following situations:
Use of CPM in the home setting for all other conditions is considered investigational.
POLICY GUIDELINESInvestigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY8/1992: Approved by Medical Policy Advisory Committee (MPAC)
2/1997: Revisions approved by MPAC:
5/2000: Revisions approved by MPAC:
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.
10/23/2013: Policy reviewed; no changes.
SOURCE(S)Blue Cross Blue Shield Association policy # 1.01.10
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.