CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Cooling Devices Used in the Home and Outpatient Setting — Payment Policy

Coverage determination for cooling devices (passive and circulating) used in home and outpatient settings for cryotherapy after surgery or injury; affects members of Blue Cross Blue Shield - Rhode Island and providers who furnish these devices.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyCooling Devices Used in the Home and Outpatient Setting — Payment Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJun 19, 2012

Next Review DateN/A

Key ActionVerify member-specific benefits and contract exclusions in the Benefit Booklet or Evidence of Coverage before dispensing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

E0218,E0236,A9270HCPCS not covered

Not applicablePrior auth

2012-06-19Effective

2021-03-17Last updated

Coverage Determination

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General coverage determination

Covered when ALL of the following are met:

Overall coverage position: Cooling devices (with or without pumping action) are considered convenience items and are not covered for Commercial products; for Medicare Advantage cooling devices will be considered not covered because the device is not reasonable and necessary.

Benefits may vary by contract; refer to the appropriate Benefit Booklet or Evidence of Coverage.

For Commercial Products, cooling devices — with or without pumping action — are considered convenience items and are not covered. Providers should note that contract exclusions apply; benefits and specific coverage may vary by member contract, so verify the member's Benefit Booklet or Evidence of Coverage for any plan-specific limitations.

Provider Requirements & Actions

Note

Prior Authorization

Prior authorization is not required for this service.

Denial Risk

Not covered — Medicare Advantage

Cooling devices will be considered not covered for Medicare Advantage plans because the device is not reasonable and necessary.

Medicare Advantage: Cooling devices deemed not reasonable and necessary

Denial Risk

Not covered — Commercial Products

For Commercial products, cooling devices (with or without pumping action) are considered convenience items and are not covered; contract exclusions apply.

Commercial: Cooling devices (including those with pumping action) — convenience items, not covered

Note

Provider note — Member benefits and verification

Benefits vary by contract. Refer to the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable exclusions and limitations. For benefit verification or questions about coverage, contact Provider Services.

Refer to Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for contract-specific exclusions and limitations
Contact Provider Services for member benefit verification

Background

Cooling devices are used to decrease local tissue temperature after surgery or musculoskeletal injury. They are available as passive (manual) units — for example, insulated containers or pads filled with iced water that rely on gravity or manual action to provide cooling and compression — and as active (motorized circulating) units that circulate chilled water and may also provide pneumatic compression. Examples of circulating systems include device families marketed as AutoChill, Game Ready, Hot/Ice Thermal Blanket, and Hilotherm. Clinical evidence from randomized trials and systematic reviews is mixed and generally insufficient to show consistent improvement in health outcomes compared with standard intermittent ice for a range of surgical indications.

Device Definitions

Passive (non-circulating) cooling device — examples and mechanism

DefinitionPassive (non-circulating) cooling devices use an insulated container filled with iced water and rely on gravity or manual action to provide cooling and compression.

ExamplesCryoCuff; Polar Care Cub.

MechanismThe CryoCuff uses an elevated insulated reservoir that fills and pressurizes a compressive cuff when raised; lowering the reservoir allows the cooled water to drain and be refilled to maintain cooling. Polar Care Cub units use pads and straps and a built-in hand pump for water movement and compression.

Typical use settingPostoperative or musculoskeletal injury cryotherapy to decrease local tissue temperature and provide compression.

Active (circulating) cooling device — motorized units that circulate chilled water

DefinitionActive (circulating) cooling devices are motorized units that circulate chilled water and may provide pneumatic compression.

ExamplesAutoChill; Game Ready Accelerated Recovery System; Hot/Ice Thermal Blanket; Hilotherm Clinic; ThermaZone; CTM 5000; cTreatment.

MechanismA motorized pump automatically exchanges and circulates cooled fluid between the main unit and wearable wraps or masks, maintaining a constant controlled temperature and optionally delivering intermittent pneumatic compression.

Typical featuresComputer-controlled temperature regulation; continuous low-temperature delivery; combinations with pneumatic compression for enhanced swelling control.

Evidence and Medical Considerations

Evidence-based considerations

Evidence summary and clinical context:

Evidence: Clinical studies (systematic reviews and randomized controlled trials) are insufficient to demonstrate consistent health outcome benefits of cooling devices (active/circulating or passive/noncirculating) compared with standard intermittent ice for indications including knee, shoulder, and facial surgery.

Several randomized trials found no significant benefit for continuous circulating devices versus intermittent ice; available trials of passive devices are limited by control conditions and inconsistent reporting of ice-change frequency.

Equipment	Rental / Purchase Rule
Cooling devices (all types; passive and active/circulating)
Not covered — considered convenience items; no rental or purchase allowed. Benefits and contract exclusions apply; verify member-specific benefits in the Benefit Booklet / Evidence of Coverage / Subscriber Agreement.

Documentation Requirements

Documentation Required

Confirm coverage before dispensing; prior authorization not applicable

Provider should confirm member coverage before dispensing cooling devices; there is no prior authorization to document under this policy.

Verify contract exclusions and member benefits in the Benefit Booklet, Evidence of Coverage, or Subscriber Agreement.
Contact the provider call center/Provider Services for member-specific information.

Noncovered Items

NOT COVERED: The following HCPCS codes and related services are not covered under this policy: E0218 (fluid circulating cold with pump, any type pad), E0236 (pump for water circulating pad), and A9270 (noncovered device or service). Claims for these items will be considered not covered and may be denied; benefits and contract exclusions apply.