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Clinical Policy Bulletin:
Continuous Passive Motion (CPM) Machines
Number: 0010


Policy

  1. Aetna considers continuous passive motion (CPM) machines medically necessary durable medical equipment (DME) to improve range of motion in any of the following circumstances:

    1. During the post-operative rehabilitation period for members who have received a total knee arthroplasty or replacement as an adjunct to on-going physical therapy (PT); or
    2. Members who have had an anterior cruciate ligament repair until the member is participating in an active PT program; or  
    3. Members undergoing surgical release of arthrofibrosis/adhesive capsulitis or manipulation under anesthesia of any joint (knee, shoulder, and elbow the commonest) until the member is participating in an active PT program; or   
    4. To promote cartilage growth and enhance cartilage healing during the non weight-bearing period following any of the following until the member begins the weight-bearing phase of recovery:
       
      1. After abrasion arthroplasty or microfracture procedure ; or 
      2. Autologous chondrocyte transplantation; or  
      3. Chondroplasties of focal cartilage defects; or  
      4. Surgery for intra-articular cartilage fractures; or  
      5. Surgical treatment of osteochondritis dissecans; or 
      6. Treatment of an intra-articular fracture of the knee (e.g., tibial plateau fracture repair); or
         
    5. Members who have undergone certain surgeries and may not be able to benefit optimally from active PT, for example members with:

      1. Dupuytren's contracture; or 
      2. Extensive tendon fibrosis; or 
      3. Mental and behavioral disorders; or 
      4. Reflex sympathetic dystrophy; or
         
    6. Members who are unable to undergo active PT.

    Note: Where the CPM device is used for surgical rehabilitation, the use of this device must commence within 2 days following surgery to meet medical necessity guidelines.  Although the usual duration of CPM usage is 7 to 10 days, up to 3 weeks of CPM therapy may be considered medically necessary upon individual consideration.  Use of the CPM machine beyond 21 days post-op is not supported by the medical literature.  There is insufficient evidence to justify use of these devices for longer periods of time or for other applications.

  2. Aetna considers CPM machines experimental and investigational for all other indications, including the ones listed below (not an all-inclusive list), because there is insufficient scientific evidence to support the use of these machines for other indications:
     
    • Motion or strength following metacarpophalangeal arthroplasty
    • Rehabilitation following back surgery
    • Rehabilitation following foot surgery
    • Rehabilitation following quadriceps tear
    • Rehabilitation following temporomandibular joint repair
    • Rehabilitation of distal radial fractures
    • Rheumatoid arthritis in the absence of a covered indication
    • Treatment of low back pain or trauma.


Background

Published studies suggest that continuous passive motion (CPM) can improve range of motion (ROM) in those patients undergoing surgical release of arthrofibrosis of the knee or manipulation of the knee under anesthesia.  In these settings, CPM provides for early post-operative motion and is considered a substitute for active PT.  Once the patient is participating in active PT, CPM is no longer medically necessary.  These observations may be extended to other joints, such as the elbow where arthrofibrosis is a common complication of trauma.

Of all the applications of CPM, the scientific evidence is perhaps strongest for its use in promoting cartilage growth.  In addition, clinical studies suggest that CPM can enhance cartilage healing during the non weight-bearing period following surgery for intra-articular cartilage fractures, chondroplasties of focal cartilage defects and surgical treatment of osteochondritis dissecans.  Once the patient is weight-bearing, CPM is no longer necessary.

Systematic evidence reviews have found weak or limited evidence for CPM for a number of indications.  In a Cochrane review, Handoll et al (2006) evaluated the effects of rehabilitation interventions in adults with conservatively or surgically treated distal radial fractures.  Fifteen trials, involving 746 mainly female and older patients, were included.  Initial treatment was conservative, involving plaster cast immobilization, in all but 27 participants whose fractures were fixed surgically.  Though some studies were well-conducted, others were methodologically compromised.  For interventions started during immobilization, there was weak evidence of improved hand function for hand therapy in the days after plaster cast removal, with some beneficial effects continuing 1 month later (1 trial).  There was weak evidence of improved hand function in the short- term, but not in the longer term (3 months), for early occupational therapy (1 trial), and of a lack of differences in outcome between supervised and unsupervised exercises (1 trial).  For interventions started post-immobilization, there was weak evidence of a lack of clinically significant differences in outcome in patients receiving formal rehabilitation therapy (4 trials), passive mobilization (2 trials), ice or pulsed electromagnetic field (1 trial), or whirlpool immersion (1 trial) compared with no intervention.  There was weak evidence of a short-term benefit of CPM (post-external fixation) (1 trial), intermittent pneumatic compression (1 trial) and ultrasound (1 trial).  There was weak evidence of better short-term hand function in participants given physiotherapy than in those given instructions for home exercises by a surgeon (1 trial).  The authors concluded that available evidence from randomized controlled trials is insufficient to establish the relative effectiveness of the various interventions used in the rehabilitation of adults with fractures of the distal radius.

A systematic evidence review by Michlovitz et al (2004) of non-surgical interventions to restore ROM to persons with injuries to the upper extremities found insufficient evidence to support the use of continuous passive motion.  The systematic evidence review identified 1 cohort study, which found CPM to be similar to ROM exercises at improving ROM and extension, but better at improving flexion, after surgery for elbow flexion contractures.  The review identified another cohort study that found CPM to be no better than passive ROM exercises after rotator cuff repair.  The investigators concluded that "[t]he quality and quantity of evidence in this area were moderate to low."

In a Cochrane review, Massy-Westropp et al (2008) compared the effectiveness of post-operative therapeutic regimens for increasing hand function following metacarpophalangeal (MCP) arthroplasty in adults with rheumatoid arthritis.  Randomized controlled trials and controlled clinical trials were accepted if they evaluated the efficacy of a post-operative therapeutic regimen for MCP arthroplasty.  No data analyses were performed as only 1 controlled clinical trial was found.  The data from that study were described.  These investigators' search only identified 1 controlled clinical trial involving 22 subjects.  The majority of the evidence for various splinting and exercise regimens consisted of case series and case studies.  Results from the 1 (poor quality) trial suggested that the use of CPM is not effective in increasing motion or strength after MCP arthroplasty.  The authors concluded that well-designed randomized controlled trials which compare the effectiveness of different therapeutic splinting programs following MCP arthroplasty are required.  At this time, the results of 1 study suggested that CPM alone is not recommended for increasing motion or strength after MCP arthroplasty.

In a randomized controlled study, Lenssen and colleagues (2008) examined the effectiveness of prolonged CPM use in the home setting as an adjunct to standardized PT.  Effectiveness was assessed in terms of faster improvements in ROM as well as functional recovery, measured at the end of the active treatment period, 17 days after surgery.  A total of 60 patients with knee osteoarthritis undergoing total knee arthroplasty (TKA) and experiencing early post-operative flexion impairment were randomized into 2 treatment groups.  The experimental group received CPM + PT for 17 consecutive days after surgery, whereas the usual care group received the same treatment during the in-hospital phase (i.e., about 4 days), followed by PT alone (usual care) in the first 2 weeks after hospital discharge.  From 18 days to 3 months following surgery, both groups received standardized PT.  The primary focus of rehabilitation was functional recovery (e.g., ambulation) and regaining ROM in the knee.  Prolonged use of CPM slightly improved short-term ROM in patients with limited ROM at the time of discharge after TKA when added to a semi-standard PT program.  Assessment at 6 weeks and 3 months after surgery found no long-term effects of this intervention.  These researchers also did not detect functional benefits of the improved ROM at any of the outcome assessments.  The authors concluded that although results indicate that prolonged CPM use might have a small short-term effect on ROM, routine use of prolonged CPM in patients with limited ROM at hospital discharge should be re-considered, since neither long-term effects nor transfer to better functional performance was detected.

In a Cochrane review, Gray et al (2012) evaluated the effectiveness of interventions for congenital talipes equinovarus (CTEV).  The review found, among other things, a lack of evidence for continuous passive motion treatment following major foot surgery. The authors could draw no conclusions from other included trials because of the limited use of validated outcome measures and lack of available raw data; and future randomized controlled trials should address these issues.

There is also a scarcity of peer-reviewed evidence on the use of CPM for other conditions including degenerative joint diseases (e.g., rheumatoid arthritis) as well as rehabilitation following quadriceps tear and temporo-mandibular joint repair.

Ring and colleagues (1998) examined if a post-operative rehabilitation protocol incorporating CPM would increase the total ROM obtained 6 months following silicone interposition arthroplasty of the metacarpophalangeal joints in patients with rheumatoid arthritis.  A prospective trial randomizing patients to receive either CPM or the standard dynamic splint protocol (modified Madden protocol) was undertaken.  A total of 15 hands (60 joints) were treated with the modified Madden protocol and 10 hands (40 joints) had CPM.  The mean 6-month post-operative ROM was 7 degrees in the modified Madden cohort compared with 39 degrees in the CPM cohort, representing an improvement of 22 degrees in the modified Madden cohort compared with an improvement of only 5 degrees in the CPM cohort.  Residual ulnar deviation 8 degrees versus 12 degrees and grip strength (2.3 kgf versus 3.7 kgf) were both lower in the CPM cohort.  The authors concluded that incorporation of the CPM machine in the post-operative rehabilitation protocol does not offer sufficient advantages to justify the added costs.

An UpToDate review on “Total joint replacement for severe rheumatoid arthritis” (Weisman and Rinaldi, 2013) states that “It is unclear whether the use of continuous passive motion devices in the postoperative management of total knee arthroplasty results in enough clinical benefit to justify the inconvenience and expense of the procedure”.

 
CPT Codes / HCPCS Codes/ ICD-9 Codes
Other CPT codes related to the CPB:
21240 - 21243
27430
97110
97140
HCPCS codes covered if selection criteria are met:
E0935 Continuous passive motion exercise device for use on knee only
E0936 Continuous passive motion exercise device for use other than knee
Other HCPCS codes related to the CPB:
E1700 Jaw motion rehabilitation system
E1701 Replacement cushions for jaw motion rehabilitation system, package of 6
E1702 Replacement measuring scales for jaw motion rehabilitation system, package of 200
E1800 Dynamic adjustable elbow extension/flexion device, includes soft interface material
E1802 Dynamic adjustable forearm pronation/supination device, includes soft interface material
E1805 Dynamic adjustable wrist extension/flexion device, includes soft interface material
E1810 Dynamic adjustable knee extension/flexion device, includes soft interface material
E1812 Dynamic knee, extension/flexion device with active resistance control
E1815 Dynamic adjustable ankle extension/flexion device, includes soft interface material
E1820 Replacement soft interface material, dynamic adjustable extension/flexion device
E1825 Dynamic adjustable finger extension/flexion device, includes soft interface material
E1830 Dynamic adjustable toe extension/flexion device, includes soft interface material
E1840 Dynamic adjustable shoulder flexion/abduction/rotation device, includes soft interface material
ICD-9 codes covered if selection criteria are met:
337.20 - 337.29 Reflex sympathetic dystrophy
717.0 - 718.4, 718.60 - 718.99 Internal derangement of knee and other joints
726.0 - 726.8 Peripheral enthesopathies and allied syndromes
728.6 Contracture of palmar fascia
732.7 Osteochondritis dissecans
844.2 Sprain of cruciate ligament of knee
905.0, 905.2 - 905.9 Late effects of musculoskeletal and connective tissue injuries (except spine)
V43.60 - V43.69 Joint replaced by other means
ICD-9 codes not covered for indications listed in the CPB:
524.60 - 524.69 Temporomandibular joint disorders
714.0 - 714.9 Rheumatoid arthritis and other inflammatory polyarthropathies [in the absence of a listed covered condition]
718.50 - 718.59 Ankylosis of joint
724.0 - 724.9 Other and unspecified disorders of back
805.00 - 806.9 Fracture of vertebral column with spinal cord injury
813.40 - 813.42, 813.44 - 813.45 Fracture of radius, lower end, closed
813.50 - 813.52, 813.54 Fracture of radius, lower end, open
813.80 - 813.81, 813.83 Fracture of radius, lower end, unspecified part, closed
813.90 - 813.91, 813.93 Fracture of radius, lower end, unspecified part, open
825.0 - 825.1 Fracture of one or more tarsal and metatarsal bones
825.20 - 825.29 Fracture of other tarsal and metatarsal bones, closed
825.30 - 825.39 Fracture of other tarsal and metatarsal bones, open
839.00 - 839.9 Dislocations of vertebra, other locations, multiple, and ill-defined
845.10 - 845.19 Sprain of foot
846.0 - 847.9 Sprains and strains of sacroiliac region or other and unspecified parts of back
905.1 Late effect of fracture of spine and trunk without mention of spinal cord lesion
907.2 Late effect of spinal cord injury
952.00 - 953.9 Spinal cord injury without evidence of spinal bone injury or injury to nerve roots and spinal plexus
959.7 Injury, knee, leg, ankle, and foot


The above policy is based on the following references:
  1. U.S. Department of Health and Human Services, Center for Medicare and Medicaid Services (CMS). Durable Medical Equipment Reference List. Coverage Issues Manual Section 60-9. Baltimore, MD: CMS; November 1996. 
  2. Dorr LD. Continuous passive motion offers no benefit to the patient. Orthopedics. 1999;22(4):393.  
  3. Yashar AA, Venn-Watson E, Welsh T, et al. Continuous passive motion with accelerated flexion after total knee arthroplasty. Clin Orthop. 1997;345:38-43. 
  4. Gaspar L, Farkas C, Szepesi K, Csernatony Z. Therapeutic value of continuous passive motion after anterior cruciate replacement. Acta Chir Hung. 1997;36(1-4):104-105.  
  5. Pope RO, Corcoran S, McCaul K, Howie DW. Continuous passive motion after primary total knee arthroplasty. Does it offer any benefits? J Bone Joint Surg Br. 1997;79(6):914-917. 
  6. Chiarello CM, Gundersen L, O'Halloran T. The effect of continuous passive motion duration and increment on range of motion in total knee arthroplasty patients. J Orthop Sports Phys Ther. 1997;25(2):119-127.  
  7. Kumar PJ, McPherson EJ, Dorr LD, et al. Rehabilitation after total knee arthroplasty: A comparison of 2 rehabilitation techniques. Clin Orthop. 1996;331:93-101.  
  8. Ververeli PA, Sutton DC, Hearn SL, et al. Continuous passive motion after total knee arthroplasty. Analysis of cost and benefits. Clin Orthop. 1995;321:208-215.  
  9. Cosgarea AJ, DeHaven KE, Lovelock JE. The surgical treatment of arthrofibrosis of the knee. Am J Sports Med. 1994;22(2):184-191.  
  10. Salter RB. The biologic concept of continuous passive motion of synovial joints. The first 18 years of basic research and its clinical application. Clin Orthop. 1989;242:12-25.  
  11. Worland RL, Arredando J, Angles F, et al. Home continuous passive motion machine versus professional physical therapy following total knee replacement. J Arthroplasty. 1998;13(7):784-787.  
  12. O'Driscoll SW, Giori NJ. Continuous passive motion (CPM): Theory and principles of clinical application. J Rehabil Res Dev. 2000;37(2):179-188.
  13. Reinecke SM, Hazard RG, Coleman K. Continuous passive motion in seating: A new strategy against low back pain. J Spinal Disord. 1994;7(1):29-35.
  14. Lenssen A F, Koke A J, de Bie R A. The effects of continuous passive motion in patients with total knee arthroplasty. Nederlands Tijdschrift voor Fysiotherapie. 2001;111(6):152-157.
  15. Ferrari J. Bunions. In: Clinical Evidence, Issue 9. London, UK: BMJ Publishing Group; June 2003.
  16. Lenssen AF, Koke AJ, De Bie RA, Geesink RG. Continuous passive motion following primary total knee arthroplasty: Short- and long-term effects on range of motion. Physical Ther Rev. 2003;8(3):113-131.
  17. Thien TB, Becker JH, Theis J-C. Rehabilitation after surgery for flexor tendon injuries in the hand. Cochrane Database Syst Rev. 2004;(4):CD003979.
  18. Michlovitz SL, Harris BA, Watkins MP. Therapy interventions for improving joint range of motion: A systematic review. J Hand Ther. 2004;17(2):118-131.
  19. Brosseau L, Milne S, Wells G, et al. Efficacy of continuous passive motion following total knee arthroplasty: A metaanalysis. J Rheumatol. 2004;31(11):2251-2264.
  20. Fuchs S, Heyse T, Rudofsky G, et al. Continuous passive motion in the prevention of deep-vein thrombosis: A randomised comparison in trauma patients. J Bone Joint Surg Br. 2005;87(8):1117-1122.
  21. Crawford K, Philippon MJ, Sekiya JK, et al. Microfracture of the hip in athletes. Clin Sports Med. 2006;25(2):327-335, x.
  22. Handoll HH, Madhok R, Howe TE. Rehabilitation for distal radial fractures in adults. Cochrane Database Syst Rev. 2006;(3):CD003324.
  23. 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):244-257.
  24. Lenssen TA, van Steyn MJ, Crijns YH, et al. Effectiveness of prolonged use of continuous passive motion (CPM), as an adjunct to physiotherapy, after total knee arthroplasty. BMC Musculoskelet Disord. 2008;9:60.
  25. Massy-Westropp N, Johnston RV, Hill C. Post-operative therapy for metacarpophalangeal arthroplasty. Cochrane Database Syst Rev. 2008;(1):CD003522.
  26. Bruun-Olsen V, Heiberg KE, Mengshoel AM. Continuous passive motion as an adjunct to active exercises in early rehabilitation following total knee arthroplasty - a randomized controlled trial. Disabil Rehabil. 2009;31(4):277-283.
  27. Lindenhovius AL, van de Luijtgaarden K, Ring D, Jupiter J. Open elbow contracture release: Postoperative management with and without continuous passive motion. J Hand Surg Am. 2009;34(5):858-865.
  28. Ferrari J, Higgins J, Prior TD. Interventions for treating hallux valgus (abductovalgus) and bunions Cochrane Database Syst Rev. 2009;(2):CD0000964.
  29. Garofalo R, Conti M, Notarnicola A, et al. Effects of one-month continuous passive motion after arthroscopic rotator cuff repair: Results at 1-year follow-up of a prospective randomized study. Musculoskelet Surg. 2010;94 Suppl 1:S79-S83.
  30. Harvey LA, Brosseau L, Herbert RD. Continuous passive motion following total knee arthroplasty in people with arthritis. Cochrane Database Syst Rev. 2010;(3):CD004260.
  31. Du Plessis M, Eksteen E, Jenneker A, et al. The effectiveness of continuous passive motion on range of motion, pain and muscle strength following rotator cuff repair: A systematic review. Clin Rehabil. 2011;25(4):291-302.
  32. Peter WF, Jansen MJ, Hurkmans EJ, et al. Physiotherapy in hip and knee osteoarthritis: Development of a practice guideline concerning initial assessment, treatment and evaluation. Acta Reumatol Port. 2011;36(3):268-281.
  33. Gray K, Pacey V, Gibbons P, et al. Interventions for congenital talipes equinovarus (clubfoot). Cochrane Database Syst Rev. 2012;(4):CD008602.
  34. Ring D, Simmons B, Hayes M. Continuous passive motion following hand metacarpophalangeal joint arthroplasty. J Hand Surg. 1998;23(3):505-511.
  35. Weisman MH, Rinaldi RZ. Total joint replacement for severe rheumatoid arthritis. Last reviewed September 2013. UpToDate Inc., Waltham, MA.


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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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