CurrentBlue Cross Blue Shield - IowaPolicy N/A

Continuous Passive Motion (CPM) Devices in the Home Setting

Policy assesses clinical evidence and coverage position for continuous passive motion (CPM) devices across postoperative and rehabilitation indications (knee, shoulder, hand, elbow, ankle, hip, stroke, etc.) and provides billing codes for DME HCPCS E0935/E0936. This part covers evidence review, supplemental guidance, codes, and policy history.

Policy Summary

PayerBlue Cross Blue Shield - Iowa

PolicyContinuous Passive Motion (CPM) Devices in the Home Setting

Policy CodePolicy N/A

Change TypeRenewal / Annual review

Effective Date

Next Review Date

Key ActionWhen requesting CPM as DME, document the specific indication, prior conservative therapy, reason for CPM (e.g., nonweight-bearing rehabilitation after knee cartilage repair or inability to participate in PT), and expected duration to justify medical necessity.

POLICY UPDATE CHANGES

Policy was reviewed May 2025 and renewed; prior reviews and revisions occurred in May 2024 and May 2023.

MultipleIndications reviewed

2Small RCTs for stroke

1Recent humeral fracture RCT (short-term benefit)

GuidelineGuideline position (AAOS/APTA)

Scope: This policy assesses continuous passive motion (CPM) devices across postoperative and rehabilitation indications (knee, shoulder, hand, elbow, ankle, hip, stroke, etc.), includes DME HCPCS codes E0935/E0936, and summarizes evidence, guidance, and policy history. Coverage stance: mixed and conditional. Last review: 2025-05. Status: CURRENT / effective.

Key stats and dates from brief

Indications reviewedMultiple indications reviewed (knee, shoulder, humerus, stroke, hand, wrist, ankle, hip, etc.)

Small randomized trials for stroke2

Recent RCT humeral ROM benefit1 (Tille et al. 2024: short-term ROM improvements at 6 weeks; no differences at 3 or 12 months)

Guideline referenceAAOS/APTA (AAOS: avoid routine CPM after knee replacement; APTA: do NOT use CPM after primary uncomplicated TKA)

Last review2025-05

Findings summarized by indication reflecting whether CPM shows clinically meaningful benefits:

Evidence-based Criteria and Indication Summaries

Evidence-based Coverage Summary (Section Summaries)

Findings summarized by indication reflecting whether CPM shows clinically meaningful benefits:

ALL of the following

Total Knee Arthroplasty (TKA) and knee cartilage repair: High-quality studies do not show improved outcomes with CPM compared to conventional therapy; guideline recommendations advise against routine use after uncomplicated primary TKA.
APTA and AAOS conclusions cited; short-term ROM differences inconsistent and not clinically significant.
Rotator cuff repair / Shoulder surgeries: Small RCTs show some short-term pain and ROM improvements but trials are low-quality and uncertain clinical significance; no long-term functional improvements demonstrated.
Optimal PT comparator unclear.
Humeral fractures (proximal humerus plate osteosynthesis): One RCT (Tille 2024) found short-term (6-week) improvements in some ROM planes; no differences at 3 and 12 months.
Small trial; short-term only.
Hand, wrist, ankle, other musculoskeletal conditions: Evidence scarce or trials show no benefit; RCTs lacking for many indications and available literature does not support postoperative CPM use for these joints.
Includes tenolysis, elbow contracture, adhesive capsulitis—mixed or limited evidence.
Stroke/neurologic rehabilitation: Two small randomized trials reported mixed results: one showed a non-significant trend for shoulder stability; one crossover trial combining exoskeleton+CPM showed improved wrist extension ROM and dexterity; small samples and short durations limit conclusions.
Home-based CPM combined with other robotic assistance in one trial; generalizability limited.
Overall conclusion: CPM may produce short-term ROM or pain improvements in select small studies, but there is insufficient high-quality evidence of long-term functional benefit across most indications; routine use is not supported.
Policy-level coverage stance is mixed and conditional based on indication and evidence; supplemental/clinical input variably supports CPM for knee cartilage repair non-weight-bearing period or when mobility/rehabilitation compliance is limited.

Not Supported Indications / Limited Evidence

Overall conclusion: routine use of CPM is not supported across most indications because randomized trials and systematic reviews generally do not demonstrate consistent high-quality evidence of durable, long-term functional benefit. Evidence for many joints and uses is scarce or negative — notably the hand, wrist, ankle and several shoulder indications show only small, short-term ROM or pain differences without lasting functional gains, and many neurologic uses (stroke) have only mixed, small trials. For knee indications, high-quality studies and guideline statements do not support routine CPM after uncomplicated primary total knee arthroplasty (TKA); evidence after knee cartilage repair is limited and inadequate to show clinical benefit. The policy therefore limits routine coverage and treats most non-knee joint uses as investigational.

Relevant Codes and Billing Context

DME HCPCS Codes for CPM devicesHCPCS

E0935	Continuous passive motion exercise device for use on knee only
E0936	Continuous passive motion exercise device for use other than knee

CPT codesCPT

None

Type of Servicemixed

Durable Medical Equipment

Place of Servicemixed

Outpatient

Billing Rule

Report appropriate HCPCS for CPM device

E0935 — Continuous passive motion exercise device for use on knee only
E0936 — Continuous passive motion exercise device for use other than knee
Use these HCPCS codes when billing as Durable Medical Equipment (DME)

Prior Authorization, Documentation & Billing

Documentation Required

Support clinical rationale when requesting CPM

Document the clinical indication, prior conservative therapy, reason for CPM (e.g., nonweight-bearing rehab after knee cartilage repair or inability to participate in PT), and expected duration to justify medical necessity.

E0935
E0936

Operational note — when CPM may be considered: CPM may be considered medically necessary as an alternative to standard physical therapy for carefully selected patients, for example during the non-weight-bearing rehabilitation period after knee cartilage repair or when an individual has low postoperative mobility or is unable to comply with active physical therapy. Documentation should specify the indication, prior conservative therapy, reason for CPM (e.g., nonweight-bearing cartilage repair period or inability to participate in PT), and expected duration.

Background and Evidence Highlights

Background: Continuous passive motion (CPM) devices mechanically move a joint passively through a controlled range of motion to maintain or improve mobility after surgery or injury. The evidence base is characterized by many small, heterogeneous trials and systematic reviews; some report inconsistent short-term improvements in range of motion or pain, but few high-quality studies show durable functional improvements or consistent clinical benefit.

Evidence Topic	Key Findings
TKA/knee cartilage repair	High-quality studies and systematic reviews do not show improved long-term outcomes with CPM compared with conventional PT for TKA; CPM after articular cartilage repair has limited clinical outcome data and systematic reviews report methodologic limitations and no definitive clinical benefit, though some histologic improvements were reported; routine use not supported except select patients unable to participate in PT.
Rotator cuff/shoulder	Several small RCTs found short-term improvements in pain or ROM with CPM after rotator cuff repair or adhesive capsulitis, but trials were low-quality, heterogeneous, and did not demonstrate long-term functional benefit; clinical significance of short-term gains is uncertain.
Humeral fractures (Tille 2024)	One RCT (Tille et al. 2024) found short-term (6-week) improvements in some ROM measures (forward flexion, adduction, abduction) with CPM after proximal humerus plate osteosynthesis; no differences at 3 or 12 months.
Stroke rehabilitation	Two small randomized trials reported mixed results: one showed a non-significant trend for improved shoulder stability with CPM; a 2022 crossover trial using exoskeleton+CPM reported improved wrist extension ROM, manual dexterity, and global symptoms, but small sample sizes and short treatment durations limit conclusions.

NCD Name	Number	Type	Effective Date
Durable Medical Equipment Reference List	280.1	NCD

Policy Summary

PayerBlue Cross Blue Shield - Iowa

PolicyContinuous Passive Motion (CPM) Devices in the Home Setting

Policy CodePolicy N/A

Change TypeRenewal / Annual review

Effective Date

Next Review Date

On This Page

OpenPayer

Continuous Passive Motion (CPM) Devices in the Home Setting

Coverage Summary

Evidence-based Criteria and Indication Summaries

Not Supported Indications / Limited Evidence

Relevant Codes and Billing Context

Prior Authorization, Documentation & Billing

Background and Evidence Highlights

Medicare Determinations

Definitions

Revision History