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Coverage criteria policies

Continuous passive motion (CPM) devices

These services may or may not be covered by all HealthPartners plans. Please see your plan documents for your own coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is required for continuous passive motion (CPM) devices after 42 days of rental.

Coverage

Continuous passive motion devices are generally covered subject to the indications listed below and per your plan documents.

Indications that are covered

  1. CPM is covered in the early postoperative period following surgery to a joint, such as total knee arthroplasty (TKA), anterior cruciate ligament (ACL) repair or contracture release. It is also covered for joint manipulation performed following a surgery.
  2. Coverage is generally limited to a maximum of 42 days rental, except as described in #3 below. The scientific evidence does not support the effectiveness of use beyond this time period.
  3. Rental of eight weeks is allowed after autologous chondrocyte implantation (ACI) only.

Definitions

Continuous passive motion (CPM) is a treatment modality in which joint motion is provided by a machine, without causing active contraction of muscle groups. This device allows passive movements to be performed to a joint for hours at a time. The joint area is secured in the CPM machine, and the machine is programmed to passively flex and extend the joint through a pre-selected range of motion and rate of repetition. The CPM device normally attaches to the extremity both above and below the joint in such a way that it will not interfere with circulation or other aspects of healing. Movement is slow and controlled, and the patient does not actively exert muscle force to move the joint.

If available, codes for a procedure, device or diagnosis are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all inclusive.

Codes

Description

E0935

Continuous passive motion exercise device for use on knee only

E0936

Continuous passive motion exercise device for use other than knee

CPT Copyright American Medical Association. All rights reserved.  CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. 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. The Journal of Arthroplasty, 29(6), 1158-1162. doi:10.1016/j.arth.2013.12.005
  2. ECRI Institute. (2018). Continuous Passive Motion Device for Aiding Recovery following Cartilage Repair Surgery. Plymouth Meeting, PA: ECRI Institute.
  3. Harvey, L. A., Brosseau, L., & Herbert, R. D. (2010). Continuous passive motion following total knee arthroplasty in people with arthritis. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.cd004260.pub2
  4. Hayes, Inc. Hayes Medical Technology Directory. Continuous Passive Motion for the Treatment of Joint Contractures of the Extremities. Lansdale, PA: Hayes, Inc. March, 2013, Reviewed March, 2014, Reviewed February, 2015 Reviewed January 2017
  5. Hayes, Inc. Hayes Medical Technology Directory. Continuous Passive Motion for knee indications. Lansdale, PA: Hayes, Inc. March, 2018
  6. Herbold, J. A., Bonistall, K., Blackburn, M., Agolli, J., Gaston, S., Gross, C., Babyar, S. (2014). Randomized Controlled Trial of the Effectiveness of Continuous Passive Motion After Total Knee Replacement. Archives of Physical Medicine and Rehabilitation, 95(7), 1240-1245. doi:10.1016/j.apmr.2014.03.012
  7. Hill, A. D., Palmer, M. J., Tanner, S. L., Snider, R. G., Broderick, J. S., & Jeray, K. J. (2014). Use of Continuous Passive Motion in the Postoperative Treatment of Intra-Articular Knee Fractures. The Journal of Bone and Joint Surgery-American Volume, 96(14). doi:10.2106/jbjs.m.00534

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Policy activity

  • 01/01/1994 - Date of origin
  • 06/01/2017 - Effective date
Review date
  • 04/2018

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