MEDICAL POLICY POLICY TITLE POLICY NUMBER CONTINUOUS PASSIVE MOTION (CPM) DEVICE MP-6.005

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1 Original Issue Date (Created): July 1, 2002 Most Recent Review Date (Revised): Effective Date: May 30, 2008 May 30, RETIRED*(see policy history) I. DESCRIPTION/BACKGROUND A Continuous Passive Motion (CPM) device is used to cause continuous passive motion of synovial joints following surgery of the hip, knee, ankle, shoulder, elbow, or wrist, traumatic injury or infection. CPM should be used as an adjunct to physical therapy with objectives to increase the duration and intensity of passive motion in order to achieve outcomes superior to that achieved by conventional physical therapy programs. CPM moves the joint continuously, allowing flexion and extension positions without patient effort. An electrical power control unit is used to set the variable range of motion (ROM) and speed, which is determined by a physical therapist or other health care professionals familiar with the device. The initial setting for ROM is based on a patient s level of comfort, joint stability and other factors that are assessed intra-operatively. The ROM is increased by 3-5 degrees as tolerated by the patient. II. III. DEFINITIONS PASSIVE MOTION is a therapeutic exercise technique used to move patients joints through ROM without patient effort. This type of therapy is accomplished by a physical therapist or with the assistance of equipment, such as a CPM device. IMMEDIATE POSTOPERATIVE PERIOD is a time period within one week of the surgical procedure. This period may be extended up to thirty days after the surgery, given individual circumstances. POLICY Use of a CPM device following major knee surgery may be considered medically necessary and appropriate when treatment is initiated during the immediate postoperative period as an adjunct to conventional physical therapy in order to: Increase the duration and intensity of passive motion; and Achieve flexibility and mobility superior to that achieved by conventional physical therapy programs alone without CPM machine. Page 1

2 Use of the device should commence within two (2) days of surgery and maximum benefit is usually obtained within fourteen (14) days from the start of therapy. Continued use beyond thirty (30) days following surgery is generally considered not medically necessary or appropriate. Use of a CPM device following major hip joint surgery will be assessed on a case-by-case basis. Such use may be considered medically necessary and appropriate when used as an adjunct to physical therapy with documentation of limited flexion and extension and associated severe pain or suspected adhesions. IV. EXCLUSIONS CPM device used for other joints including, but not limited to, the shoulder is considered not medically necessary, as there is no conclusive evidence that it clearly improves long term outcomes compared with other techniques. V. BENEFIT VARIATIONS The existence of this medical policy does not mean that this service is a covered benefit under the member's contract. Benefit determinations should be based in all cases on the applicable contract language. Medical policies do not constitute a description of benefits. A member s individual or group customer benefits govern which services are covered, which are excluded, and which are subject to benefit limits and which require preauthorization. Members and providers should consult the member s benefit information or contact Capital for benefit information. VI. DISCLAIMER Capital s medical policies are developed to assist in administering a member s benefits, do not constitute medical advice and are subject to change. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any medical policy related to their coverage or condition with their provider and consult their benefit information to determine if the service is covered. If there is a discrepancy between this medical policy and a member s benefit information, the benefit information will govern. Capital considers the information contained in this medical policy to be proprietary and it may only be disseminated as permitted by law. VII. REFERENCES BCBSA Technology Evaluation Center Evaluations 1993: Tab 6. BCBSA TEC Assessment 1997, Tab 20. Continuous Passive Motion as an Adjunct to Physical Therapy for Joint Rehabilitation. Chen B, Zimmerman JR, Soulen L et al. Continuous passive motion after total knee arthroplasty: a prospective study. Am J Phys Med Rehabil 2000; 79(5): Centers for Medicare and Medicaid Services (CMS) National Coverage Determination (NCD) 280.1, Durable Medical Equipment Reference List. Effective 5/5/2005. CMS Page 2

3 %3A280%2E1%3A2%3ADurable+Medical+Equipment+Reference+List. Accessed February 4, Cohen D. Treatment Uninterrupted. Rehab Management. June Accessed February 4, Denis, M, Moffet, H, Caron, F et al. Effectiveness of continuous passive motion and conventional physical therapy after total knee arthroplasty: a randomized clinical trial. Phys Ther. 2006;86(2): ECRI Hotline Report, Continuous Passive Motion Devices following Orthopedic Surgery. Updated 3/19/2007. Hammesfahr R, Serafino M. CPM: The Key to Successful Rehabilitation. Orthopedic Technology Review, Vol. 3, Number 2, 2002, pp Handoll, HH, Madhok, R, and Howe, TE. Rehabilitation for distal radial fractures in adults. Cochrane Database Syst Rev. 2006;(3):CD Lynch, D, Ferraro, M, Krol, J et al. Continuous passive motion improves shoulder joint integrity following stroke. Clin Rehabil. 2005;19(6): MacDonald SJ, Bourne RB, Rorabeck CH et al. Prospective randomized clinical trial of continuous passive motion after total knee arthroplasty. Clin Orthop 2000; 380: Michael, JW, Konig, DP, Imhoff, AB et al. Efficiency of a postoperative treatment after rotator cuff repair with a continuous passive motion device (CPM). Z Orthop Ihre Grenzgeb. 2005;143(4): Milne S, Brosseau L, Robinson V et al. Continuous passive motion following total knee arthroplasty (Cochrane Review) In: The Cochrane Library, Issue 3, Cochrane ml. Accessed February 4, O Driscoll SW, Giori NJ. Continuous passive motion (CPM): Theory and principles of clinical application. Journal of Rehabilitation Research and Development, 2000; 37(2). Postel JM, Thoumie P, Missaoui B et al. French Physical Medicine and Rehabilitation Society. Continuous passive motion compared with intermittent mobilization after total knee arthroplasty. Elaboration of French clinical practice guidelines. Ann Readapt Med Phys 2007; 50(4): Page 3

4 Thien TB, Becker JH, and Theis JC. Rehabilitation after surgery for flexor injuries in the hand. (Cochrane Review) In: The Cochrane Library, Issue 4, Cochrane ml. Accessed February 4, Yip, Jeff. "Keep it Moving". Orthopedic Technology Review, 2001; 3 (5). Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company and Keystone Health Plan Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. Page 4

5 VIII. PRODUCT VARIATIONS [N] = No product variation, policy applies as stated [Y] = Standard product coverage varies from application of this policy, see below [N] CHIP POS [N] PPO [N] HMO [N] CHIP HMO [N] SeniorBlue PPO [Y] FEP PPO* [N] Indemnity [N] SpecialCare [N] POS [Y] FEP HMO* [N] SeniorBlue * The FEP program dictates that all drugs, devices or biological products approved by the U.S. Food and Drug Administration (FDA) may not be considered investigational. Therefore, FDA-approved drugs, devices or biological products may be assessed on the basis of medical necessity. IX. POLICY HISTORY CAC 11/26/02 CAC 5/27/03 CAC 9/28/04 CAC 9/27/05 Policy retired CAC 5/30/06 Medical Policy Reinstated CAC 2/27/07 Policy approved for retirement effective 5/30/2008. Policy retired and combined into Mechanical Stretching Devices for Contracture and Joint Stiffness Page 5