Continuous Passive Motion (CPM) Device in the Home Setting
Does not apply to Medicare Advantage
DESCRIPTION
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 (CPM) 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. CPM 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 its use for other weight-bearing joints (hip, ankle, and metatarsals) as well as non-weight-bearing joints (shoulder, elbow, metacarpals, interphalangeal joints) and other conditions such as stroke.
The device used for the knee moves the joint (flexion and extension) without manual assistance, continuously for extended periods of time (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 an individual’s level of comfort and other factors assessed intraoperatively. The range of motion is increased by three to five 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 time.
POLICY
Use of a continuous passive motion (CPM) device in the home setting is considered medically necessary as an adjunct to physical therapy if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Use of a continuous passive motion (CPM) device in the home setting as an adjunct to physical therapy for all other conditions/ diseases is considered investigational.
MEDICAL APPROPRIATENESS
Continuous passive motion (CPM) is considered medically appropriate if ALL of the following criteria are met:
In the home setting as an adjunct to physical therapy when ANY ONE of the following are met:
Low postoperative mobility or inability to comply with rehabilitation exercises following either total knee arthroplasty (TKA) or TKA revision (e.g., individuals 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)
Intra-articular cartilage repair procedure of the knee (e.g., microfracture; osteochondral grafting; autologous chondrocyte implantation; treatment of osteochondritis dissecans; repair of tibial plateau fractures) during the non-weight-bearing rehabilitation period
IMPORTANT REMINDERS
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan or government program (e.g., TennCare), the express terms of the health plan or government program will govern.
Does not apply to Medicare Advantage
SOURCES
American Academy of Orthopaedic Surgeons. (2015). Surgical management of osteoarthritis of the knee; evidence based clinical practice guideline. Retrieved March 28, 2017 from ebm@aaos.org.
BlueCross BlueShield Association. Evidence Positioning System. (4:2023). Continuous passive motion in the home setting (1.01.10). Retrieved November 17, 2023 from https://www.bcbsaoca.com/eps/. (54 articles and/or guidelines reviewed)
Boese, C.K., Weis, M., Phillips, T., Lawton-Peters, S., Gallo, T., & Centeno, L. (2014). The efficacy of continuous passive motion after total knee arthroplasty: a comparison of three protocols. Journal of Arthroplasty, 29 (6), 1158-1162. Abstract retrieved March 12, 2018 from PubMed database.
Centers for Medicare & Medicaid Services. CMS.gov. National Coverage Determination (NCD) for Durable Medical Equipment Reference List (280.1). Retrieved November 17, 2023 from https://www.cms.gov.
Chaudhry, H. & Bhandari, M. (2015). Cochrane in CORR®: Continuous passive motion following total knee arthroplasty in people with arthritis (review). Clinical Orthopaedics and Related Research, 473, 3348–3354. (Level 1 evidence)
Culvenor, A. G., Girdwood, M. A., Juhl, C. B., Patterson, B. E., Haberfield, M. J., Holm, P. M., et al. (2022). Rehabilitation after anterior cruciate ligament and meniscal injuries: a best-evidence synthesis of systematic reviews for the OPTIKNEE consensus. British Journal of Sports Medicine, 56 (24), 1445–1453. (Level 1 evidence)
Nikolaou, V.S., Chytas, D., & Babis, G.C. (2014). Common controversies in total knee replacement surgery: current evidence. World Journal of Orthopedics, 5 (4), 460-468. (Level 2 evidence)
Winifred S. Hayes, Inc. Medical Technology Directory. (2018, March; last update search March 2022). Continuous passive motion for knee indications. Retrieved November 7, 2022 from www.Hayesinc.com/subscribers. (35 articles and/or guidelines reviewed)
Winifred S. Hayes, Inc. Medical Technology Directory. (2018, May; last update search May 2022). Continuous passive motion devices for shoulder indications. Retrieved November 7, 2022 from www.Hayesinc.com/subscribers. (36 articles and/or guidelines reviewed)
Yang, X., Li, G.H., Wang, HJ., & Wang, CY. (2019). Continuous passive motion after total knee arthroplasty: A systematic review and meta-analysis of associated effects on clinical outcomes. Archives of Physical Medicine and Rehabilitation, 100 (9), 1763-1778. Abstract retrieved November 7, 2022 from PubMed database.
ORIGINAL EFFECTIVE DATE: 11/1986
MOST RECENT REVIEW DATE: 12/14/2023
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Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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