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DESCRIPTIONCold 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 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 devices, a motorized pump both circulates cold 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 then 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.
POLICYActive and passive cooling devices are considered not medically necessary.
Combination active cooling and compression (cryopneumatic) devices are 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.
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.
SOURCE(S)Blue Cross Blue Shield Association policy # 1.01.26
CODE REFERENCEThis is not an all-inclusive list of non-covered procedure codes.
All codes billed for this procedure are considered non-covered and not eligible for coverage.