CurrentBlue Cross Blue Shield - MassachusettsPolicy 510

Cold and compression (cryotherapy) devices

Defines Blue Cross Blue Shield Massachusetts coverage stance for active circulating and noncirculating cold and compression therapy devices for commercial members, including investigational determinations, prior authorization requirements and coding information for outpatient/inpatient settings.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyCold and compression (cryotherapy) devices

Policy CodePolicy 510

Change TypeAnnual policy review (references updated)

Effective Date

Next Review Date

Key ActionPrecertification/preauthorization is required for products described in this policy if the procedure is performed inpatient.

POLICY UPDATE CHANGES

Annual policy review: Policy updated with literature review through January 17, 2025; references added; policy statements unchanged.

2HCPCS codes listed as investigational

Not coveredCommercial outpatient coverage

YesPreauthorization required (inpatient)

Coverage Summary

Scope: Defines Blue Cross Blue Shield Massachusetts coverage stance for active circulating and noncirculating cold and compression (cryotherapy) devices for commercial members, including investigational determinations, prior authorization requirements and coding information for outpatient and inpatient settings.

Overview: Coverage stance is not covered (investigational/not covered for outpatient commercial members). For Commercial Members (Managed Care HMO and POS; PPO; Indemnity) both active and passive cooling devices and combination cryopneumatic devices are designated investigational, outpatient services described in this policy are not a covered service for Commercial Managed Care, PPO, and Indemnity, and precertification/preauthorization is required if performed inpatient.

Key Facts

policy_number510

subjectCold and compression (cryotherapy) devices

coverage_stanceInvestigational / Not covered for Commercial outpatient (active and passive cooling devices INVESTIGATIONAL)

last_review2025-05-01

precertification_requirementPrecertification/preauthorization is required for products described in this policy if the procedure is performed inpatient.

Preauthorization requiredInpatient

Coverage statusCommercial outpatient — not a covered service

Coding

Investigational HCPCS codes (Commercial Members)HCPCSNot Covered

E0218	Water circulating cold with pump pad
E0236	Pad

Informational / general coding guidancemixed

No codes listed

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

Provider Actions & Billing Impact

Prior Authorization

Inpatient precertification required

Precertification/preauthorization is required for products described in this policy if the procedure is performed inpatient.

Denial Risk

Outpatient noncoverage for Commercial members

Claims for outpatient use of cooling devices described in this policy for Commercial Managed Care (HMO and POS), Commercial PPO and Indemnity are not a covered service and are at risk for denial or nonpayment.

Documentation Required

Report current industry-standard codes

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

Background & Evidence

Cooling devices include both active circulating devices (motorized pump circulates chilled water and may provide pneumatic compression — examples: AutoChill, Game Ready) and passive noncirculating devices (gravity-fed or manually filled insulated containers and pads — examples: CryoCuff, Polar Care Cube). These devices are typically used postoperatively to provide cryotherapy and, in some systems, pneumatic compression as an alternative to traditional ice packs and compressive wraps.

High-level evidence statement: Randomized controlled trials and systematic reviews provide mixed results; some trials show no significant benefit while others show small or inconsistent benefits (for example, an opioid reduction in one trial). Overall the evidence is insufficient to demonstrate consistent improvement in net health outcomes for many indications.

Evidence Summary

Literature review dateJanuary 17, 2025

RCT resultsMixed; several RCTs and systematic reviews show mixed benefits — some trials show no significant benefit, others show small or inconsistent benefits (eg, opioid reduction in one trial).

Definitions referencedDefinitions provided for Active circulating cooling device, Noncirculating cooling device, and Investigational (see policy definitions).

Active circulating cooling device: A motorized pump circulates chilled water and may also provide pneumatic compression (examples: AutoChill, Game Ready).

Noncirculating cooling device: Passive devices that use gravity or manual filling of an insulated tank or pads to provide cooling and sometimes compression (examples: CryoCuff, Polar Care Cube).

Investigational: Devices or device uses determined investigational by this policy and therefore not covered for Commercial members (policy makes investigational determinations for active and passive cooling devices and combination cryopneumatic devices).