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MP 1.01.10  

Continuous Passive Motion  (CPM) in the Home Setting


Medical Policy    

Section
Durable Medical Equipment

Original Policy Date   
11/30/96

Last Review Status/Date
Reviewed with literature search/7:2013

Issue
7:2013
 

Return to Medical Policy Index


Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically. 


Description

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

Background

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

The device moves the joint (e.g., flexion/extension), without patient assistance, continuously for extended periods of time, i.e., up to 24 hours/day. An electrical power unit is used to set the variable range of motion (ROM) and speed. The initial settings for ROM are based on a patient’s level of comfort and other factors that are assessed intraoperatively. The ROM is increased by 3–5 degrees per day, as tolerated. The speed and ROM can be varied, depending on joint stability. The use of the devices may be initiated in the immediate postoperative period and then continued at home for a variable period of time.


Policy

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

Under conditions of low postoperative mobility or inability to comply with rehabilitation exercises following a total knee arthroplasty (TKA) or TKA revision. This may include patients 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.

  • 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).

Use of CPM in the home setting for all other conditions is considered not medically necessary.


Policy Guidelines

The original policy did not make a distinction between home and inpatient use of CPM. The current policy only addresses CPM in the home setting (i.e., not the hospital setting).

Following total knee arthroplasty (TKA), continuous passive motion (CPM) in the home setting will be allowable for up to 17 days after surgery while patients are immobile or unable to bear weight.

Following intra-articular cartilage repair procedures of the knee, CPM in the home setting will be allowable for up to 6 weeks during non-weight-bearing rehabilitation.


Benefit Application

BlueCard/National Account Issues

When offered in the home setting, CPM may be adjudicated under durable medical equipment (DME) benefits. In other settings, CPM may be adjudicated as a form of physical therapy.

State or federal mandates (e.g., FEP) may dictate that all FDA-approved devices, drugs, or biologics may not be considered investigational, and thus these devices may be assessed only on the basis of their medical necessity.


Rationale

This policy was created in November, 1996. Literature review updates of the MEDLINE database, focusing on randomized trials of continuous passive motion (CPM) used in the home setting, were performed periodically through May 30, 2013. The majority of studies identified focused on the use of CPM in the knee. Therefore, the following discussion focuses on different surgical procedures for the knee, followed by a review of literature regarding CPM for other joints.

The original medical policy was based on a 1997 TEC Assessment that concluded that CPM met the TEC criteria as an adjunct to physical therapy in patients undergoing total knee arthroplasty (TKA). (1) Early studies of CPM machines focused on their use in the hospital setting, in which frequently the impact on length of stay was considered a key clinical outcome, and the TEC Assessment did not specifically examine the place of service of CPM or the length of time that the CPM machines were used. For example, a critical study identified in the TEC Assessment was a randomized study by McInnes et al. that examined the use of CPM initiated in the immediate postoperative period and continued throughout the 7-day hospital stay. (2) At 6 weeks postoperatively, the most salient difference in the 2 groups was an increased incidence of arthrofibrosis requiring manipulation in the non-CPM group. However, this study did not focus on the use of CPM in the home. In the other articles reviewed for the TEC Assessment, CPM was typically used for 7 days or less. The 1997 TEC Assessment concluded that at the time of review, other applications of CPM did not meet the TEC criteria.

Over the past 10-20 years, hospital lengths of stay have progressively shortened, and in some cases, surgical repair may be done either as an outpatient or with a length of stay of 1–2 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. Therefore, some providers may wish to continue CPM in the home as a means of duplicating the services offered with a longer (7-day) hospital stay. The focus of the current policy is to examine the literature regarding home use of CPM as it is currently being prescribed postoperatively. The most important comparisons will be treatment outcomes of CPM when used alone or in addition to conventional physical therapy, compared to conventional physical therapy alone.

Total Knee Arthroplasty (TKA)

Early Postoperative Period: Efficacy in the early postoperative period has been cited to support the continued use of these devices in the home setting following early discharge. CPM after TKA was the subject of a 2003 Cochrane review. (3) This review reported that CPM combined with physical therapy was found to statistically significantly increase active knee flexion and decrease length of stay. However, the analysis suggests that the benefits of CPM in a hospital setting may be small and only short term. (4) This Cochrane review was updated in 2010. (5) The updated review included 20 randomized trials with 1,335 participants and examined short-term (<6 weeks), medium-term (6 weeks to 6 months), and long-term (>6 months) effects of CPM. Most of the included studies examined short-term effects. The review found that there was high-quality evidence that CPM increases passive knee flexion ROM (mean difference 2 degrees) and active knee flexion ROM (mean difference 3 degrees), but the effects were too small to be clinically worthwhile. There was no significant effect of CPM on knee extension. Lower quality evidence indicated that CPM has no effect on length of hospital stay (mean difference -0.3 days), but data from 3 trials suggest that CPM may reduce the need for manipulation under anesthesia (1 event for CPM vs. 12 events for control, relative risk [RR]: 0.15). The review concluded that the effects of CPM on knee ROM are too small to justify its use but that there is weak evidence that CPM reduces the subsequent need for manipulation under anesthesia.

Earlier studies in the hospital setting focused on whether the use of CPM is safe (i.e., whether it has an impact on healing of tissues), what ROM can be tolerated at what point in the postoperative recovery, and whether the use of CPM permits earlier hospital discharge by accelerating the recovery of ROM. For example, Yashar and colleagues reported on a trial that randomly assigned 178 patients undergoing TKA to CPM immediately in the postoperative period or to CPM 1 day after surgery. A small but statistically significant improvement in flexion was found at the time of discharge in those started on early CPM, but this difference did not persist at 4 weeks. (6) MacDonald and colleagues reported on a randomized trial focusing on immediate postoperative versus no postoperative CPM in a group of patients undergoing TKA. (7) Patients received a maximum of 24 hours with CPM. There were no differences in the treatment groups regarding ROM, length of stay, or analgesic requirements. In the trial reported by Pope and colleagues, 53 patients were randomly assigned either to 2 different schedules of CPM versus no CPM. The use of CPM was not associated with improved function or range of motion (ROM). (8) Kumar and colleagues randomly assigned 73 patients who had undergone TKA to receive either CPM in the immediate postoperative period versus protocol of early passive flexion referred to as the "drop and dangle" technique. (9) Patients assigned to the drop and dangle technique were discharged from the hospital earlier and also had a statistically better extension range at 6 months compared to the CPM group.

More recent randomized controlled trials (RCTs) find that 2-4 hours of daily CPM in the hospital after total knee replacement does not improve postoperative outcomes at discharge or follow-up. (10-12) For example, Bruun-Olsen and colleagues randomly assigned 67 patients undergoing TKA to receive active physiotherapy exercises with or without CPM to assess whether there was short-term benefit on pain or function. (10) In both groups, exercises were performed daily for 30 minutes, starting 1 day after surgery until discharge at 1 week. For the experimental group, CPM was provided for 4 hours on the day of surgery, followed by 6 hours daily in addition to therapist-guided exercises. Blinded assessment at 1 week and 3 months after surgery showed similar results for pain and function in the 2 groups; at 1 week, both groups had visual analog scale (VAS) pain ratings of 40 and flexion scores that were within 2 degrees of each other. Functional testing at 3 months showed no benefit of adjunctive CPM. The lack of improvement with CPM in recent studies may be due to the current practice of permitting patients to mobilize or commence flexion immediately following surgery. (12)

Inpatient Rehabilitation Hospital: Chen and colleagues randomly assigned 51 patients in an inpatient rehabilitation service who had undergone TKA to receive conventional active physical therapy or physical therapy plus CPM. (13) Referral to the rehabilitation center was made 5–6 days after surgery, and the majority had received CPM as part of the initial hospitalization. Knee flexion was the principal outcome. No significant difference was noted in range of passive motion between the 2 groups, as measured on admission, on the third and seventh days and at the time of discharge (8 days after admission). Thus, the use of CPM in the rehabilitation hospital offered no added benefit. While a rehabilitation service does not duplicate the home environment, it does reflect the use of CPM beyond the initial acute hospitalization.

A retrospective comparative study by Herbold et al. evaluated use of CPM in 61 matched pairs of patients admitted to a rehabilitation hospital. (14) Outcomes following use of CPM were compared with those from a cohort of 61 inpatients who also had poor initial ROM, defined as less than 75 degrees of active knee flexion at the time of admission, and matched for postoperative day at admission, age, length of stay, and Health Insurance Prospective Payment System (HIPPS) code. Use of CPM (2 hours per day) was determined primarily by the referring physician, and was used in 29% of the pool of 633 patients who had poor initial ROM. The average length of stay was 7.85 days. There were no significant differences in outcomes at discharge, including knee flexion or extension, discharge to the community, need for home care services, need for an assistive device, or functional scores on the HIPPS.

Home Setting: A study by Worland and colleagues was the only identified controlled study that compared the use of CPM and active physical therapy in the home setting. In this study, 80 patients undergoing TKA were randomly assigned to receive, at discharge, home CPM (3 hours/day for 10 days) versus active physical therapy, as offered by professional physical therapists. (15) The vast majority of studies have examined CPM as an adjunct to active physical therapy; therefore, this study is unique in that CPM is proposed as an alternative. At 2 weeks, knee flexion was similar in the 2 groups, but a flexion contracture was noted in 1 patient in the CPM-only group. At 6 months, no differences were found in knee scores or knee flexion.

In another study, 60 patients with limited flexion range of motion (<80 degrees) at the time of hospital discharge were assigned to standard physical therapy alone or in combination with CPM in the home (4 hours per day) until assessment on postoperative day 17. (16) Blinded assessment showed a trend for an increase in ROM for the CPM group (e.g., 89 degrees vs. 84 degrees, respectively, p=0.07), with no differences in function between the groups, as measured by the Knee Society Score (function subscore 43 vs. 40, respectively) or the Western Ontario and McMaster Universities Arthritis Index) (WOMAC) difficulty score (49 vs. 45, respectively). No differences were observed between groups in ROM or function at the 6-week or 3-month assessment. No differences were observed for the secondary outcome measures (perceived effect, medication use, satisfaction with treatment, adherence) at any of the assessment times. Since benefit for long-term ROM or functional recovery was not detected, the authors questioned whether routine use of CPM following hospital discharge should be continued.

Section Summary. Numerous randomized controlled trials (RCTs) have been performed comparing CPM as an adjunct to physiotherapy for patients undergoing TKA. Early trials generally used CPM in the inpatient setting and are less relevant to today’s practice patterns of short hospital stays followed by outpatient rehabilitation. Some of these trials report an improvement in range of motion for patients receiving CPM, but these improvements are short term, of small magnitude, and of uncertain clinical significance. No RCTs have reported clinically meaningful improvements in important clinical outcomes such as functional status and/or quality of life. As a result, the evidence is not sufficient to determine that the use of CPM improves outcomes for the majority patients undergoing TKA.

The above conclusions assume that patients are able to undergo standard physical therapy programs. For patients who are unable to participate in the standard physical therapy regimens, due to limited mobility or behavioral/psychological factors, standard physical therapy is not an option. For these patients, CPM can be used as an alternative to physical therapy and is expected to be superior to no physical therapy.

Anterior Cruciate Ligament Repair

The literature search did not identify any additional RCTs of CPM in the home setting after repair of the anterior cruciate ligament (ACL). Therefore, the studies of CPM after ACL repair in the immediate postoperative period may possibly be relevant to the home setting for patients who are discharged with an abbreviated hospital stay. The 1997 TEC Assessment concluded that CPM in the immediate postoperative period as an adjunct to conventional physical therapy offered no demonstrable advantage over conventional physical therapy alone. (1) In a 2008 systematic review of ACL reconstruction rehabilitation, Wright et al. discussed 6 randomized trials on CPM that had been published prior to 1996; no randomized controlled studies published after the 1997 TEC Assessment were identified. (17) The review found no substantial advantage for CPM use and concluded that CPM for ACL rehabilitation could not be justified. Wright and colleagues also noted that most current ACL rehabilitation protocols initiate early motion within the first postoperative week.

Cartilage Repair of the Knee

Although no RCTs were identified that compared health outcomes with or without the use of CPM, CPM is routinely used as a part of the rehabilitation protocol for as long as 6 weeks when weight bearing is restricted following autologous chondrocyte implantation. (18-20) Basic research is cited that supports greater healing of articular cartilage of full-thickness defects that penetrate the subchondral bone than either immobilization or intermittent mobilization. (21, 22)

In 2010, Fazalare and colleagues published a systematic review of CPM following knee cartilage defect surgery. (23) The review found use of CPM following autologous chondrocyte implantation, microfracture, and osteochondral autografts and allografts in numerous studies in the previous 5 years. Four level III (cohort) studies with 262 patients were identified that specifically compared CPM to no CPM; no randomized trials were identified. Procedures in these 4 studies included microfracture, periosteal transplant of the patella, and high tibial osteotomy with either diagnostic arthroscopy or abrasion arthroplasty. CPM regimens ranged from 6 days to 8 weeks. Heterogeneity in the studies and outdated surgical techniques limit conclusions from these trials.

Hip

The literature search did not identify any controlled studies focusing on CPM of the hip after surgical intervention. One pilot study looked at the use of CPM of the hip in patients with osteoarthritis in the absence of surgical intervention. (24) This uncontrolled study examined the use of CPM for 1 to 7 hours daily for a 12-week trial. While improvements were noted in the patient's assessment of pain, a controlled trial is needed to validate this treatment effect, particularly in comparison to a program of regular walking.

Rotator Cuff

Passive shoulder motion has been studied after shoulder surgery, particularly after repair of the rotator cuff. Du Plessis et al. published a systematic review of CPM following rotator cuff repair in 2011, with a literature search performed in 2009. (25) Three RCTs with a total of 113 patients were included in the review. A meta-analysis could not be conducted due to heterogeneity in populations studied, outcome measurements and tools, interventions and comparisons. Two of the RCTs included in this review were the studies by Lastayo et al. and Raab et al. discussed below. (26, 27) The third study included in the systematic review was a German language report that found a significant reduction of 12 days in the time to reach 90 degree abduction compared to a physiotherapy control group, with no significant difference in pain between the 2 groups.

The 2 RCTs included in the systematic review were small. Lastayo and colleagues reported the results of a trial that randomly assigned 31 patients undergoing rotator cuff repair to 1 of 2 types of postoperative management: a 4-week home program of CPM (average of 3 hours per day) or manual passive elevation and rotation exercises. (26) No significant difference in outcomes was observed between the 2 approaches. Raab and colleagues conducted a trial that randomly assigned 26 patients to undergo postoperative physical therapy alone or CPM in addition to physical therapy. (27) Patients were evaluated with pre- and 3-month postoperative shoulder scores that incorporated pain, function, muscle strength, and ROM. A significant improvement was found in the subscore of ROM, although there was no significant improvement in overall shoulder score in the CPM group compared to the control group. Both of these RCTs were likely underpowered to show differences on important clinical outcomes.

In 2010, Garofalo et al. reported another randomized study on the effects of CPM after rotator cuff repair. (28) All of the 100 patients underwent passive self-assisted ROM exercise, with additional use of CPM in roughly half of the patients for 2 hours per day (4 sessions of 30 min. each) over 4 weeks. The physiotherapist-supervised exercises included pendulum movements and progressive passive abduction, forward flexions, and external rotation. Otherwise, the shoulder was immobilized in a sling brace for 4 weeks after surgery. From the 5th to the 28th week, all patients underwent the same physical therapy protocol. ROM and VAS for pain were measured at 2.5, 6, and 12 months by an independent examiner. In the CPM group, VAS was slightly better at 2.5-month follow-up (7.5 vs. 9.1), but not at the 6-month (0.5 vs. 0.6) or 12-month (0.2 vs. 0.2 – all respectively) evaluation. Use of pain medication was not examined. ROM was significantly better in the group of patients who used CPM at 2.5-month follow-up (e.g., forward flexion of 133.0 vs. 120.7) and 6 months (158.1 vs. 151.7), but not at 12 months (165.2 vs. 158.0 – all respectively).

Section Summary. Three small RCTs of CPM post-rotator cuff surgery have been identified in the English language literature. Two of these trials report short-term improvements in ROM for patients undergoing CPM, and one reports a short-term reduction in pain. None of the trials report long-term improvements, nor are there any reported benefits in functional status or quality of life. Therefore, the clinical significance of the short-term improvements reported is uncertain. In addition, there is uncertainty about the optimal physical therapy regimen post-shoulder surgery such that the optimal comparison for CPM is not clear. Larger RCTs with longer follow-up are required to determine whether CPM following rotator cuff surgery results in clinically meaningful improvements in health outcomes.

Adhesive Capsulitis of the Shoulder

Dundar et al. compared CPM with physiotherapy in a randomized trial of 57 patients with adhesive capsulitis (frozen shoulder). (29) CPM or physiotherapy was provided for 1 hour per day (5 days a week) for 4 weeks. Pain and function were similar in the 2 groups at baseline, with VAS scores for pain ranging from 5.44 (at rest) to 6.34 (with movement). Assessments at baseline, 4, and 12 weeks showed improvements in pain and function in both groups. CPM resulted in better pain reduction than physiotherapy (at rest, 47% vs. 25%; with movement, 35% vs. 21%; and at night, 36% vs.19%, all respectively). There were no differences between groups in ROM or functional ability. Although this unblinded study provides some support for the inclusion of CPM in a physiotherapy program, additional studies are needed to evaluate CPM when provided at home.

Stroke

CPM is also being studied as a means to aid recovery of motor skills following stroke. One study randomly assigned 35 patients to daily sessions of CPM (25 min) or daily group therapy sessions consisting of self-range motion for post-stroke rehabilitation. (30) All patients also received standard post-stroke therapy for 3.5 hours per day. Following 20 days of therapy, there was a trend for greater shoulder joint stability in the passive motion group (n=17, p <0.06) compared with the control group (n=15). No statistically significant differences were found for measures of motor impairment. This study is limited by the small sample size and the short follow-up period; additional studies are needed to determine whether treatment with passive motion over a longer duration could aid in the recovery of motor skills following stroke.

Elbow

Postoperative management of open elbow contracture release with CPM was assessed in a matched cohort study by Lindenhovius et al. (31) Sixteen patients who had used CPM after open contracture release and 16 patients who had not used CPM after surgery were matched for age, gender, diagnosis, ROM, and radiographic appearance. Chart review was utilized when possible; patients who had insufficient follow-up in the medical record were invited back for follow-up and radiograph. Twenty-three patients (72%) were evaluated by an investigator who was not involved in their care. Improvements in ROM were not different between the 2 groups for either early (4–10 months) or final (10–56 months) evaluations.

Hand

The 1997 TEC Assessment reviewed a multicenter study of CPM in patients who had undergone flexor tendon repair. (32) The TEC Assessment concluded that data were inadequate to permit scientific conclusions regarding these applications. Ring and colleagues examined the role of CPM in 15 hands (60 joints) undergoing silicone interposition arthroplasty of the metacarpophalangeal joint secondary to rheumatoid arthritis. (33) Patients were randomly assigned to receive a 6-week protocol CPM plus the standard dynamic splint protocol versus the dynamic splint protocol alone. The authors did not identify any clear advantages of adding CPM to the standard protocol. A retrospective chart review compared 15 patients who had received CPM after tenolysis with 21 who did not. (34) The patients who received CPM improved total active motion 40 degrees (from 137 degrees to 177 degrees), while patients who did not receive CPM improved motion 32 degrees (from 152 degrees to 184 degrees). This was not significantly different. Although the CPM users had more therapy visits, it was not known why some patients had been prescribed CPM and others had not. Interpretation of this uncontrolled study is limited.

Foot

One study compared passive motion versus immobilization following surgical treatment of idiopathic club foot in 38 infants (50 feet). (35) The infants were randomly assigned to CPM (4 hours each day) or casting during days 10–42 following surgery. Blinded analysis showed improvements in the Dimeglio clubfoot score (9.7 to 3.1) that were significantly greater than in the control group (10.3 to 4.2, respectively) through 12 months (97% follow-up). Between 12 and 18 months, this trend reversed and by 48 months after surgery, there was no significant difference between the 2 groups. Compliance with this treatment may be low. (36)

Clinical Input Received through Physician Specialty Societies and Academic Medical Centers

While the various physician specialty societies and academic medical centers may collaborate with and make recommendations during this process, through the provision of appropriate reviewers, input received does not represent an endorsement or position statement by the physician specialty societies or academic medical centers, unless otherwise noted.

2008

In response to requests, input was received from 1 physician specialty society and 2 academic medical centers while this policy was under review in 2008. The 3 reviewers interpreted the existing literature as providing support for the use of CPM for the knee for at least 7 days postoperatively, whether in the hospital or home, and suggested that longer use of CPM would be warranted for special conditions.

2010

In response to requests, input was received from 2 physician specialty societies and 5 academic medical centers while this policy was under review in 2010. Overall, clinical input supported the use of CPM under conditions of low postoperative mobility or inability to comply with rehabilitation exercises following a TKA or TKA revision or during the non-weight-bearing rehabilitation period following intra-articular cartilage repair procedures of the knee. Support was limited for use of CPM in joints other than the knee, or in situations/conditions other than those described in this policy.

Summary

The majority of research on continuous passive motion (CPM) has been as a postoperative treatment for total knee arthroplasty (TKA). Studies conducted in a controlled hospital setting suggest that CPM can improve rehabilitation when postoperative mobility is restricted. However, current postoperative rehabilitation protocols are considerably different than when the largest body of evidence was collected, making it difficult to apply the available evidence to the present situation. Recent literature suggests that home use of CPM has minimal benefit when combined with standard physical therapy after TKA. For patients who are unable to participate in standard physical therapy regimens, CPM remains an alternative physical therapy modality. Therefore, based on clinical input and consideration of the available literature, CPM in the home setting may be considered medically necessary after TKA as an adjunct to physical therapy, under conditions of low postoperative mobility or inability to comply with rehabilitation exercises. CPM may also be considered medically necessary for patients in the non-weight bearing period following intra-articular cartilage repair procedures of the knee.

For joints other than the knee, there is limited published evidence. There is some evidence that use of CPM following rotator cuff repair of the shoulder improves short-term pain and range of motion (ROM); however, this is not high-quality evidence, and the small differences in outcomes may not be clinically important. Use of CPM in the home under all other conditions has not been shown to improve health outcomes and is thus considered not medically necessary.

Practice Guidelines and Position Statements

Clinical practice guidelines from the French Physical Medicine and Rehabilitation Society conclude that evidence is not sufficient to recommend substituting CPM for other rehabilitation techniques aimed at early mobilization after TKA. (37) The evidence review found no positive effect of CPM over intermittent early mobilization, at short- or long-term follow-up.

Medicare National Coverage

Medicare National Coverage Determinations (NCD)-Durable Medical Equipment Reference List (280.1) Manual 100-3 "Continuous passive motion devices are devices covered for patients who have received a total knee replacement. To qualify for coverage, use of the device must commence within 2 days following surgery. In addition, coverage is limited to that portion of the three week period following surgery during which the device is used in the patient's home. There is insufficient evidence to justify coverage of these devices for longer periods of time or for other applications." (38)

References:

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  31. Lindenhovius AL, van de Luijtgaarden K, Ring D et al. Open elbow contracture release: postoperative management with and without continuous passive motion. J Hand Surg Am 2009; 34(5):858-65.
  32. Gelberman RH, Nunley JA, 2nd, Osterman AL et al. Influences of the protected passive mobilization interval on flexor tendon healing. A prospective randomized clinical study. Clin Orthop Relat Res 1991; (264):189-96.
  33. Ring D, Simmons BP, Hayes M. Continuous passive motion following metacarpophalangeal joint arthroplasty. J Hand Surg Am 1998; 23(3):505-11.
  34. Schwartz DA, Chafetz R. Continuous passive motion after tenolysis in hand therapy patients: a retrospective study. J Hand Ther 2008; 21(3):261-6; quiz 67.
  35. Zeifang F, Carstens C, Schneider S et al. Continuous passive motion versus immobilisation in a cast after surgical treatment of idiopathic club foot in infants: a prospective, blinded, randomised, clinical study. J Bone Joint Surg Br 2005; 87(12):1663-5.
  36. Kasten P, Geiger F, Zeifang F et al. Compliance with continuous passive movement is low after surgical treatment of idiopathic club foot in infants: a prospective, double-blinded clinical study. J Bone Joint Surg Br 2007; 89(3):375-7.
  37. Postel JM, Thoumie P, Missaoui B et al. Continuous passive motion compared with intermittent mobilization after total knee arthroplasty. Elaboration of French clinical practice guidelines. Ann Readapt Med Phys 2007; 50(4):244-57.
  38. Center for Medicare and Medicaid. NCD for Durable Medical Equipment Reference List (280.1). 5/5/2005. Available online at: http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=280.1&ncd_version=2&basket=ncd%3A280%2E1%3A2%3ADurable+Medical+Equipment+Reference+List. Last accessed June, 2011. 

Codes

Number

Description

CPT 

 

No applicable codes

ICD-9 Diagnosis 

337.22

Reflex sympathetic dystrophy of the lower limb

   715.16 Osteoarthrosis, localized, primary, lower leg
   715.26 Osteoarthrosis, localized, secondary, lower leg
   715.36 Osteoarthrosis, localized, not specified whether primary or secondary, lower leg
   715.96 Osteoarthrosis, unspecified whether generalized or localized, lower leg
   716.16 Traumatic arthropathy, lower leg
    717.83 Old disruption anterior cruciate ligament
   718.06 Articular cartilage disorder, lower leg
   718.56 Ankylosis of joint, lower leg (includes arthrofibrosis of knee)
   718.86 Other joint derangement, lower leg
   719.86 Other specified disorders of joint, lower leg
   732.7 Osteochondritis dissecans
   821.20-821.39 Fracture of lower end of femur, code range
   822.0-822.1 Fracture of patella, code range
    823.00, 823.10 Fracture of upper end of tibia, code list
    959.7 Injury, other and unspecified, knee, leg, ankle, and foot
   V43.65 Organ or tissue replaced by other means, joint, knee
   V54.81 Aftercare following joint replacement

HCPCS 

E0935 

Continuous passive motion exercise device for use on knee only 

  E0936 CPM device, other than knee

 

E1399 

Durable medical equipment, miscellaneous 

ICD-10-CM (effective 10/1/14) G57.70-G57.72 Causalgia of lower limb (Includes complex regional pain syndrome II of lower limb)
  G90.521-G90.529 Complex regional pain syndrome I of lower limb, code range
   M12.561-M12.569 Traumatic arthropathy, knee, code range
   M17.0-M17.9 Osteoarthritis of knee, code range
   M23.50-M23.52 Chronic instability of knee, code range
   M23.8x1-M23.92 Other and unspecified internal derangement of knee, code range
   M24.661 – M24.669 Ankylosis, knee, code range
   M93.261 – M93.269 Osteochondritis dissecans, knee, code range
   S72.401A – S72.499S Fracture of lower end of femur, code range
   S82.001A – S82.099S Fracture of patella, code range (7th characters C, F, J, N, or R do not apply in this code range)
   S82.101A – S82.199S Fracture of upper end of tibia, code range
   S89.90xA – S89.92xS Unspecified injury of lower leg, code range
   Z47.1 Aftercare following joint replacement surgery (used with code from Z96.6xx to identify joint)
  Z96.651 – Z96.659 Presence of artificial knee joint, code range
ICD-10-PCS (effective 10/1/14)    Not applicable. Policy is only for outpatient services.

Type of Service 

Durable Medical Equipment 

Place of Service 

Outpatient 


Index

Continuous Passive Motion Device
Device, Continuous Passive Motion
Joint Rehabilitation, Continuous Passive Motion


Policy History

Date Action Reason
11/15/96 Add policy to Durable Medical Equipment section, Medical Equipment subsection New policy
10/08/02 Replace policy Policy revised to focus on home use of CPM for the knee; this application considered not medically necessary. Prior policy did not distinguish between home use and use in acute care setting
12/17/03 Replace policy Policy updated with literature review. No changes in policy statement. Reference added regarding Cochrane Review
04/1/05 Replace policy Policy updated with literature review. No changes in policy statement
10/01/05 Replace policy Updated to local policy
04/17/07 Replace Policy Updated to local policy
12/11/08 Replace policy  Return to active review and updated with literature search, clinical input reviewed; 10 references added and references reordered; policy statement changed to medically necessary under specified conditions
07/08/10 Replace policy Policy updated with literature review through January 2010, 2 references added; clinical input reviewed; policy statements unchanged
7/14/11 Replace policy Policy updated with literature review through May 2011; references 8, 22, 26 added and references reordered; policy statements unchanged
07/12/12 Replace policy Policy updated with literature review through May 2012; reference 24 added; policy statements unchanged
7/11/13 Replace policy Policy updated with literature review through May 30, 2013; reference 14 added; policy statements unchanged