BlueCross and BlueShield of Montana Medical Policy/Codes
Continuous Passive Motion (CPM) Device
Chapter: Durable Medical Equipment
Current Effective Date: July 18, 2013
Original Effective Date: January 01, 1988
Publish Date: April 18, 2013
Revised Dates: August 25, 2004; March 1, 2010; March 16, 2011; August 17, 2012; April 17, 2013
Description

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; reduce local edema; and prevent 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 intra-operatively.  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

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply.  If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Medically Necessary

BCBSMT may consider Continuous Passive Motion (CPM) device medically necessary for use postoperatively as an adjunct to conventional physical therapy in the following situations ONLY:

  • 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.  Use of the CPM device must begin within 48 hours of the surgical procedure (or on discharge from facility following the procedure) and may continue for ONLY up to 21 days postoperatively. OR
  • For up to 6 weeks 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, reconstruction of the anterior cruciate ligament [ACL]).

Investigational

BCBSMT considers all other uses of a CPM device experimental, investigational and unproven, including but not limited to the following:

  • Postoperative rehabilitation for the following:
    1. Shoulder surgery,
    2. Total hip replacement (THR),
    3. Temporomandibular joint (TMJ) surgery, or
    4. Ankle or toe surgery, including bunionectomy;
  • All surgical procedures on the knee not specified in this policy as being medically necessary;
  • Prevention of thrombosis following ankle surgery;
  • Rehabilitation of the shoulder, elbow or hand;
  • Treatment of osteoarthritis in the shoulder, hip, or any other major joint;
  • Aiding in the clearance of infection from a septic joint;
  • Treatment of hemarthrosis in hemophiliac patients;
  • Treatment of contractures caused by burns, trauma, and Dupuytren's contractures;
  • Treatment of any other conditions not listed above.

Rationale

A 1997 Blue Cross Blue Shield Association (BCBSA) Technology (TEC) Assessment concluded that CPM met the TEC criteria as an adjunct to physical therapy in patients undergoing total knee arthroplasty.  However, this TEC Assessment did not specifically examine the place of service of CPM or the length of time that the CPM machines were used.  A critical study identified in the TEC Assessment was a randomized study by McInnes that examined the use of CPM initiated in the immediate postoperative period and continued throughout the seven-day hospital stay.  At six weeks’ postoperatively, the most salient difference in the two groups (CPM and non-CPM) 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 seven days or less.  The 1997 TEC Assessment concluded that at the time of review, other applications of CPM did not meet the TEC criteria.

In recent 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.  Therefore, with early discharge, some providers may wish to continue CPM in the home as a means of duplicating the services offered with a longer (seven-day) hospital stay.  The focus of the current policy is to examine the literature regarding home use of CPM.  It specifically examines the treatment outcome of CPM when used alone or when used in addition to conventional physical therapy compared to physical therapy alone.

As part of the 2011 update, a search of peer reviewed literature was performed to identify new clinical trial publications or any additional information that would change the coverage position of this medical policy, and the entire Rationale has been revised.  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.

Total Knee Arthroplasty (TKA)

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 (three hours/day for 10 days) versus active physical therapy, as offered by professional physical therapists.  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 two weeks, knee flexion was similar in the two groups, but a flexion contracture was noted in one patient in the CPM only group.  At six months, no differences were found in knee scores or knee flexion.

In another study, 60 patients with limited flexion range of motion (< 80°) at the time of hospital discharge were assigned to standard physical therapy alone or in combination with CPM in the home (four hours per day) until assessment on postoperative day 17.  Blinded assessment showed a trend for an increase in range of motion for the CPM group (e.g., 89° vs. 84°, p = 0.07), with no differences in function between the groups as measured by the Knee Society Score (function subscore 43 vs. 40) or the WOMAC [Western Ontario and McMaster Osteoarthritis Index] difficulty score (49 vs. 45).  No differences were observed between groups in range of motion or function at the six-week or three-month assessments.  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 range of motion or functional recovery was not detected, the authors questioned whether routine use of CPM following hospital discharge should be continued.

Chen and colleagues randomized 51 patients in an inpatient rehabilitation service who had undergone TKA to receive conventional active physical therapy or physical therapy plus CPM.  Referral to the rehabilitation center was made five to six 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 two groups, as measured on admission, on the third and seventh hospital days, and at the time of discharge (eight days after admission).  The authors concluded that 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.

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, which 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.

The 2003 Cochrane review was updated in 2010.  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 three trials suggest that CPM may reduce the need for manipulation under anesthesia (one event for CPM vs. 12 events for control, relative risk [RR]: 0.15).  The authors 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.

Other studies in the hospital setting have focused on whether the use of CPM is safe (i.e., whether or not it impacts on healing of tissues), what range of motion can be tolerated at what point in the postoperative recovery, and whether or not the use of CPM permits earlier hospital discharge by accelerating the recovery of range of motion.  Yashar and colleagues reported on a trial that randomized 178 patients undergoing TKA to CPM immediately in the postoperative period or to CPM one 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 four weeks.  MacDonald and colleagues reported on a randomized trial focusing on immediate postoperative versus no postoperative CPM in a group of patients undergoing TKA.  Patients received a maximum of 24 hours with CPM.  There were no differences in the treatment groups regarding range of motion, length of stay, or analgesic requirements.  In the trial reported by Pope and colleagues, 53 patients were randomized either to two different schedules of CPM versus no CPM.  The use of CPM was not associated with improved function or range of motion. Kumar and colleagues randomized 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.  Patients assigned to the drop and dangle technique were discharged from the hospital earlier and also had a statistically better extension range at six months compared to the CPM group.

More recent randomized controlled trials find that two to four hours of daily CPM in the hospital after total knee replacement does not improve postoperative outcomes at discharge or follow-up.  For example, Bruun-Olsen and colleagues randomized 67 patients undergoing TKA to receive active PT exercises with or without CPM to assess whether there was short-term benefit on pain or function.  In both groups, exercises were performed daily for 30 minutes, starting one day after surgery until discharge at one week.  For the experimental group, CPM was provided for four hours on the day of surgery, followed by six hours daily in addition to therapist-guided exercises. Blinded assessment at one week and three months after surgery showed similar results for pain and function in the two groups; at one week, both groups had VAS pain ratings of 40 and flexion scores that were within two degrees of each other.  Functional testing at three 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.

Anterior Cruciate Ligament (ACL) Repair

The literature search did not identify any additional randomized controlled trials of CPM after repair of the ACL in the home setting.  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 BCBSA 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.  In a 2008 systematic review of ACL reconstruction rehabilitation, Wright et al. discussed six randomized trials on CPM that had been published prior to 1996; no randomized-controlled studies published after the 1997 BCBSA TEC Assessment were identified.  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 institute early motion within the first postoperative week.

Cartilage Repair of the Knee

Although no controlled clinical studies were identified, basic research supports greater healing of articular cartilage of full-thickness defects that penetrate the subchondral bone than either immobilization or intermittent mobilization.  CPM has been used as a part of the rehabilitation protocol for as long as six weeks when weight bearing is restricted following autologous chondrocyte implantation (ACI).  In addition, use of CPM following ACI is also supported by controlled studies of CPM that have been done for TKA of the knee and show benefit under conditions of immobility.

In 2010, Fazalare and colleagues published a systematic review of CPM following knee cartilage defect surgery.  The review found use of CPM following autologous chondrocyte implantation, microfracture, and osteochondral autografts and allografts in numerous studies in the previous five 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 four studies included microfracture, periosteal transplant of the patella, and high tibial osteotomy with either diagnostic arthroscopy or abrasion arthroplasty.  CPM regimens ranged from six days to eight 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.  This uncontrolled study examined the use of CPM for one to seven 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.  Lastayo and colleagues reported on the results of a trial that randomized 31 patients undergoing rotator cuff repair to one of two types of postoperative management: a four-week home program of continuous passive motion (average of three hours per day) or manual passive elevation and rotation exercises.  No significant difference in outcomes was observed between the two approaches, although the study may have been underpowered.  Raab and colleagues conducted a trial that randomized 26 patients to undergo postoperative physical therapy alone or CPM in addition to physical therapy.  Patients were evaluated with pre- and three-month postoperative shoulder scores that incorporated pain, function, muscle strength, and range of motion.  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.  This study may also have been underpowered. 

In 2010, Garofalo et al. reported a randomized study on the effects of CPM after rotator cuff repair.  All of the 100 patients underwent passive self-assisted ROM exercise, with additional use of CPM in roughly half of the patients for two hours per day (four sessions of 30 min. each) over four 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 four 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).

This trial has several limitations.  It is unclear whether the degree of difference in ROM or pain, or the time period for these differences, represents a clinically important effect.  In addition, there are differing opinions about whether the standard of care should be passive mobilization or immobilization after rotator cuff repair.  Finally, the CPM group had two more hours of passive motion per day, and it is unclear whether the differences in pain and ROM would persist if the control group spent an equal amount of time with self-assisted ROM exercise.

Adhesive Capsulitis of the Shoulder

Dundar et al. compared CPM with physiotherapy in a randomized trial of 57 patients with adhesive capsulitis (frozen shoulder).  CPM or physiotherapy was provided for one hour per day (five days a week) for four weeks.  Pain and function were similar in the two 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 randomized 35 patients to daily sessions of CPM (25 min) or daily group therapy sessions consisting of self-range motion for post-stroke rehabilitation.  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.  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 two groups for either early (4–10 months) or final (10–56 months) evaluations.

Hand

The 1997 BCBSA TEC Assessment reviewed a multicenter study of CPM in patients who had undergone flexor tendon repair.  The TEC Assessment concluded that there were inadequate data 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.  Patients were randomized 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.  The patients who received CPM improved total active motion 38° (from 137° to 177°), while patients who did not receive CPM improved motion 24° (from 152° to 184°).  This was not significantly different, and 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).  The infants were randomized to CPM (four hours each day) or casting during days 10–42 following surgery.  Blinded analysis showed improvements in the Dimeglio club foot score (9.7 to 3.1) that were significantly greater than the control group (10.3 to 4.2) 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 two groups.  Compliance with this treatment may be low.

Summary

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 total knee arthroplasty.  However, studies conducted in a controlled hospital setting do suggest that CPM can improve rehabilitation when post-operative mobility is restricted.  Therefore, CPM in the home setting may be considered medically necessary after some knee joint surgeries as an adjunct to physical therapy, under conditions of low postoperative mobility or inability to comply with rehabilitation exercises.  There is some evidence that use of CPM following rotator cuff repair of the shoulder improves short-term pain and ROM; however, this is not high-quality evidence, and the differences in the outcome measures may not be clinically important.  Use of CPM in the home under all other conditions has not been shown to improve health outcomes.

Coding

Disclaimer for coding information on Medical Policies           

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy.  They may not be all-inclusive.           

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers.  Only the written coverage position in a medical policy should be used for such determinations.           

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps. 

ICD-9 Codes

337.22, 715.16, 715.26, 715.36, 715.96, 716.16, 717.83, 718.06, 718.56, 718.86, 719.86, 732.7, 821.20-821.39, 822.0-822.1, 823.00, 823.10, 959,7, V43.65 , V54.81

ICD-10 Codes

G57.70-G57.72, G90.521-G90.529,  M12.561-M12.569,  M17.0-M17.9,  M23.50-M23.52,  M23.8x1-M23.92,  M24.661 - M24.669,  M93.261 - M93.269,  S72.401A - S72.499S,  S82.001A - S82.099S,  S82.101A - S82.199S,  S89.90xA - S89.92xS,  Z47.1,  Z96.651 - Z96.659

Procedural Codes: E0935, E0936, E1399
References
  1. 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 Relat Res 1989; (242):12-25.
  2. Gelberman RH, Nunley JA, Osterman AL et al.  Influences on the protected passive mobilization interval on flexor tendon healing.  A prospective randomized clinical study.  Clin Orthop 1991; 264:189- 96.
  3. McInnes, J., Larson, M.G., et al.  A controlled evaluation of continuous passive motion in patients undergoing total knee arthroplasty.  Journal of the American Medical Association (JAMA) (1992) 268(11):1423-8.
  4. 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.
  5. Raab MG, Rzeszutko D, O'Connor W et al.  Early results of continuous passive motion after rotator cuff repair: a prospective, randomized, blinded, controlled study.  Am J Orthop (Belle Mead NJ) 1996; 25(3):214-20.
  6. Pope RO, Corcoran S, McCaul K et al.  Continuous passive motion after primary total knee arthroplasty.  Does it offer any benefits?  J Bone Joint Surg Br 1997; 79(6):914-7.
  7. Continuous Passive Motion as an Adjunct to Physical Therapy for Joint Rehabilitation.  Chicago, Illinois: Blue Cross Blue Shield Association – Technology Evaluation Center Assessment Program (1997 January) 11(20):1-15.
  8. 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.
  9. Ring D, Simmons BP, Hayes M.  Continuous passive motion following metacarpophalangeal joint arthroplasty.  J Hand Surg [Am] 1998; 23(3):505-11.
  10. Lastayo, P.C., et al.  Continuous passive motion after repair of the rotator cuff.  A prospective outcome study.  Journal of Bone and Joint Surgery - American Volume (1998 July) 80(7):1002-11.
  11. Worland, R.L., et al.  Home continuous passive motion machine versus professional physical therapy following total knee replacement.  Journal of Arthroplasty (1998 October) 13(7):784-7.
  12. Simkin, P.A., et al.  Continuous passive motion for osteoarthritis of the hip: a pilot study.  Journal of Rheumatology (1999 September) 26(9):1987-91.
  13. 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):421-6.
  14. MacDonald SJ, Bourne RB, Rorabeck CH et al.  Prospective randomized clinical trial of continuous passive motion after total knee arthroplasty.  Clin Orthop 2000; 380:30-5.
  15. Milne, S., Brosseau, L., et al.  Continuous passive motion following total knee arthroplasty.  Cochrane Database System Review (2003) (2):CD004260.
  16. Brosseau, L., Milne, S., et al.  Efficacy of continuous passive motion following total knee arthroplasty: a metaanalysis.  Journal of Rheumatology (2004 November) 31(11):2251-64.
  17. Browne JE, Anderson AF, Arciero R et al.  Clinical outcome of autologous chondrocyte implantation at 5 years in US subjects.  Clin Orthop Relat Res 2005; (436):237-45.
  18. Lynch D, Ferraro M, Krol J et al.  Continuous passive motion improves shoulder joint integrity following stroke.  Clin Rehabil 2005; 19(6):594-9.
  19. 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.
  20. 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):174-85.
  21. Leach W, Reid J, Murphy F.  Continuous passive motion following total knee replacement: a prospective randomized trial with follow-up to 1 year.  Knee Surg Sports Traumatol Arthrosc 2006; 14(10):922-6.
  22. 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.
  23. Postel, J.M., Thoumie, P., et al.  Continuous passive motion compared with intermittent mobilization after total knee arthroplasty.  Elaboration of French clinical practice guidelines.  Annales de Readaptation et de Medecine Physique (2007 May) 50(4):244-57.
  24. Nugent-Derfus GE, Takara T, O'neill JK, et al.  Continuous passive motion applied to whole joints stimulates chondrocyte biosynthesis of PRG4.  Osteoarthritis Cartilage 2007; 15(5):566-74.
  25. Farr J.  Autologous chondrocyte implantation improves patellofemoral cartilage treatment outcomes.  Clin Orthop Relat Res 2007; 463:187-94.
  26. Rosenberger RE, Gomoll AH, Bryant T et al.  Repair of large chondral defects of the knee with autologous chondrocyte implantation in patients 45 years or older.  Am J Sports Med 2008; 36(12):2336-44.
  27. 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.
  28. Wright RW, Preston E, Fleming BC, et al.  A systematic review of anterior cruciate ligament reconstruction rehabilitation: part I: continuous passive motion, early weight bearing, postoperative bracing, and home-based rehabilitation.  J Knee Surg 2008; 21(3):217-24.
  29. 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.
  30. 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):277-83.
  31. Dundar U, Toktas H, Cakir T et al.  Continuous passive motion provides good pain control in patients with adhesive capsulitis.  Int J Rehabil Res 2009; 32(3):193-8.
  32. 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.
  33. Harvey LA, Brosseau L, Herbert RD.  Continuous passive motion following total knee arthroplasty in people with arthritis.  Cochrane Database Syst Rev 2010; (3):CD004260.
  34. Fazalare JA, Griesser MJ, Siston RA et al.  The use of continuous passive motion following knee cartilage defect surgery: a systematic review.  Orthopedics 2010; 33(12):878.
  35. 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:S79-83.
  36. Continuous Passive Motion (CPM) in the Home Setting.  Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2011 July) Durable Medical Equipment 1.01.10.
History
August 2012  Policy updated with literature review through May 2012; reference 24 added; policy statements unchanged
April 2013 Title changed from "Continuous Passive Motion Device in the Home Setting" to "Continuous Passive Motion (CPM) Device".  Criteria added to Medically Necessary statement that CPM for low postoperative mobility must begin within 48 hours of the surgical procedure and may continue for only 21 days.  Criteria added that CPM may be Medically Necessary only up to 6 weeks during the non-weight bearing status.  Not Medically Necessary statement changed to Investigational.  Rationale and references updated.
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Continuous Passive Motion (CPM) Device