BlueCross and BlueShield of Montana Medical Policy/Codes
Heat and Cold Therapy Devices
Chapter: Therapies
Current Effective Date: August 27, 2013
Original Effective Date: May 19, 1999
Publish Date: August 27, 2013
Revised Dates: September 1, 2011; April 6, 2012; July 19, 2013
Description

Heat or cold therapy may be used for any of the following:

  • post-operatively (e.g., after total knee replacement or hip arthroplasty or anterior cruciate ligament repair), or
  • immediately following injury, or
  • before or after physical therapy sessions, or
  • to reduce muscle spasm and improve flexibility of tendons and ligaments; or
  • improve circulation; or
  • relieve pain; or
  • typical athletic cold therapy sessions in order to lower skin temperature and reduce swelling thus decrease bleeding and possibly reduce pain medication requirements. 

Methods of administering heat or cold therapy include:

  • Cryogenic machines attached to insulated blankets, or
  • Water circulating cold pads (e.g., Polar Care Cold Therapy Pads), or
  • Cold packs (e.g., ice, gel, chemical, etc.), or
  • Vasopneumatic cryotherapy devices (e.g., Game Ready ™), (delivers active compression and cold therapy and runs on AC power or optional battery pack)
  • Electric and non-electric dry or moist heat pads; or
  • Heat wraps.
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.

Not Medically Necessary

Blue Cross and Blue Shield of Montana (BCBSMT) considers the following heat and cold therapy devices are considered convenience items and not durable medical equipment and therefore not medically necessary:

  • A device in which ice water is put in a reservoir and then circulated through a pad by means of gravity, or
  • Motorized water circulating cold pads (e.g., including but not limited to, Polar Care Therapy Pads), or 
  • Cryogenic machines attached to an insulated disposable blanket , or
  • Vasopneumatic cryotherapy devices (e.g., including but not limited to, Game Ready ™), or
  • Non-electric moist or dry heat pads; or
  • Heat or cold wraps of any type; or
  • Similar products.

NOTE:  Heat or cold packs (e.g., ice, gel, chemical, etc.), hot water bottles, ice bags, etc., are supplies purchased over the counter without a prescription.  Over the counter supplies are generally contract exclusions.  Member contract benefit may vary.  Check contracts for coverage eligibility.

Rationale
 
Heat and cold therapy, particularly post-operative cold therapy, are standard treatment modalities that can be provided by a variety of methods.  None has been demonstrated in clinical trials to demonstrate health benefit over others, or over simple compress.

Convenience items are items that are primarily used for the convenience of the patient. 

Water circulating cold pads (e.g.., Polar Care Cold Therapy Pads) or a cryogenic machine attached to an insulated disposable blanket or similar products are considered convenience items since the same outcome can be achieved with over the counter cold packs.

Heat and cold wraps and packs, ice bags, and hot water bottles are not considered DME and can be purchased over the counter without a prescription.

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

Refer to the ICD-9-CM manual.

Procedural Codes: A9273, E0218, E0221, E0236
References
  1. Finan, M.A, Roberts, W.S., et al.  The effects of cold therapy on postoperative pain in gynecologic patients: a prospective, randomized study.  American Journal of Obstetrics and Gynecology (1993 February) 168(2): 542-4.
  2. Daniel, D.M., Stone, M.L.,  et al. The effect of cold therapy on pain, swelling, and range of motion after anterior cruciate ligament reconstructive surgery.  Arthroscopy (1994 October) 10(5): 530-3,.
  3. Leutz, D.W., H. Harris.  Continuous cold therapy in total knee arthroplasty. American Journal of Knee Surgery (1995 Fall) 8(4): 121-3.
  4. Scarcella, J.B., B.T. Cohn.  The effect of cold therapy on the post-operative course of total hip and knee arthroplasty patients.
  5. American Journal of Orthopedics (1995 November) 24(11): 847-52.
  6. Konrath, G.A.,T. Lock.: The use of cold therapy after anterior cruciate ligament reconstruction.  The American Journal of Sports Medicine (1996 September-October) 24(5): 629-33.
  7. Konrath, G.A.,T. Lock. The use of cold therapy in the post-operative management of patients undergoing arthroscopic anterior cruciate ligament reconstruction The American Journal of Sports Medicine (1996 March-April) 24(2): 193-5.
  8. Barber, F.A., McGuire, D.A., et al.  Continuous flow cold therapy for outpatient anterior cruciate ligament reconstruction. Arthroscopy (1998 March) 14(2): 130-5.
  9. Palmetto GBA, DMERC, Medical Policy: Cold Therapy. (2003 Spring) Revision, 1-6.
  10. Airaksinen, O.V., Kyeklund, N., et al.  Efficacy of cold gel for soft tissue injuries: a prospective randomized double-blinded trial.  American Journal of Sports Medicine (2003 September-October) 31(5): 680-4.
History
September 2011 Policy updated with literature review through December 2010; policy statement unchanged
April 2012 Policy updated with literature review through November 2011; need for policy affirmed; policy statement unchanged
August 2013 Policy formatting and language revised.  Policy statement unchanged.  Policy now addresses heating devices.  Title changed from "Cooling Devices Used in the Outpatient Setting" to "Heat and Cold Therapy Devices".
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Heat and Cold Therapy Devices