Continuous Passive Motion in the Home Setting

POLICY NUMBER

A.1.01.10

DESCRIPTION

Continuous passive motion devices are used to keep a joint in motion without patient assistance. Continuous passive motion is being evaluated for treatment and postsurgical rehabilitation of the upper- and lower-limb joints and for a variety of musculoskeletal conditions.

Physical therapy of joints following surgery focuses both on passive motion to restore mobility and on active exercises to restore strength. While passive motion can be administered by a therapist, continuous passive motion devices have also been used. Continuous passive motion is thought to improve recovery by stimulating the healing of articular tissues and the circulation of synovial fluid; reducing local edema; and preventing adhesions, joint stiffness or contractures, or cartilage degeneration. Continuous passive motion has been investigated primarily in the knee, particularly after total knee arthroplasty or ligamentous or cartilage repair. Acceptance of its use in the knee joint has created interest in continuous passive motion use for other weight-bearing joints (i.e., hip, ankle, metatarsals) as well as non-weight-bearing joints (i.e., shoulder, elbow, metacarpals, and interphalangeal joints). Use of continuous passive motion in stroke and burn patients is also being explored.

The device used for the knee moves the joint (e.g., flexion and extension) without patient assistance, continuously for extended periods of time (ie, up to 24-hours/day). An electrical power unit is used to set the variable range of motion and speed. The initial settings for range of motion are based on a patient's level of comfort and other factors that are assessed intraoperatively. The range of motion is increased by three to five degrees per day, as tolerated. The speed and range of motion can be varied, depending on joint stability. The use of the device may be initiated in the immediate postoperative period and then continued at home for a variable period of time.

Over time, hospital lengths of stay have progressively shortened and, in some cases, surgical repair is done as an outpatient or with a length of stay of 1 to 2 days. As a result, there has been a considerable shift in the rehabilitation regimen, moving from an intensive in-hospital program to a less intensive outpatient program. Some providers may want patients to continue continuous passive motion in the home setting as a means of duplicating services offered with a longer (7-day) hospital stay.

The focus of the current review is to examine the literature on the use of continuous passive motion in the home setting as it is currently being prescribed postoperatively. Relevant comparisons are treatment outcomes of continuous passive motion when used alone or with physical therapy, compared with physical therapy alone.

Continuous passive motion devices are considered class I devices by the U.S. Food and Drug Administration and are exempt from 510(k) requirements. This classification does not require submission of clinical data on efficacy but only notification of the FDA prior to marketing.Note: The policy only addresses CPM in the home setting.

POLICY

Use of continuous passive motion in the home setting may be considered medically necessary as an adjunct to physical therapy in the following situations:

Use of continuous passive motion in the home setting for all other conditions is considered investigational.

POLICY EXCEPTIONS

None

POLICY GUIDELINES

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

Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:

A.  consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and

B.  appropriate with regard to standards of good medical practice; and

C.  not solely for the convenience of the Member, his or her Provider; and

D.  the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.

For the definition of medical necessity, “standards of good 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. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.

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.

POLICY HISTORY

8/1992: Approved by Medical Policy Advisory Committee (MPAC).

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.

10/23/2013: Policy reviewed; no changes.

08/19/2014: Policy reviewed; description updated. Policy statement regarding the use of CPM in the home setting for all other conditions revised to change "investigational" to "not medically necessary."

08/26/2015: Medical policy revised to add ICD-10 codes.

10/28/2015: Policy description updated regarding devices. Policy statements unchanged. Policy guidelines updated to add medically necessary and investigative definitions.

05/26/2016: Policy number A.1.01.10 added.

08/05/2016: Policy description updated. Policy statements unchanged.

03/23/2017: Policy description updated. Policy statements unchanged.

08/07/2017: Medically necessary policy statement updated to change "intra-articular" to "articular."

03/28/2018: Policy reviewed; no changes.

04/02/2019: Policy reviewed; no changes.

04/13/2020: Policy reviewed; no changes.

09/29/2020: Code Reference section updated to add new ICD-10 diagnosis codes M05.7A, M05.8A, M06.0A, M06.8A, and M24.89, effective 10/01/2020.

05/21/2021: Second policy statement updated to change "not medically necessary" to "investigational." Policy intent unchanged. Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity."

04/25/2022: Policy reviewed; no changes.

04/10/2023: Policy description updated. Policy statement updated to change "patients" to "individuals."

07/05/2023: Policy reviewed; no changes.

04/10/2024: Policy reviewed; no changes.

06/06/2024: Policy reviewed; no changes.

08/04/2025: Policy reviewed; no changes.

SOURCE(S)

Blue Cross Blue Shield Association policy # 1.01.10

CODE REFERENCE

This 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. 

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

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