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Continuous Passive Motion (CPM) Devices
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This policy governs Cigna coverage determinations for continuous passive motion (CPM) devices used in rehabilitation after surgery or for other conditions, and applies to health benefit plans administered by Cigna Companies.
No material clinical or coverage changes in this revision.
Coverage Determination and Rationale
Overall coverage determination
Covered when ALL of the following are met:
Cigna policy statement
Evidence-based coverage considerations
Coverage considerations based on available evidence and professional guidance:
See cited randomized trials and cohort studies in the literature review
AAOS: strong evidence of no benefit; APTA: recommendation against use for primary uncomplicated TKA
See upper extremity trial summaries
The policy position is explicit: the use of a continuous passive motion (CPM) device is considered not medically necessary for ANY indication. Claims for CPM are therefore subject to denial under this policy. The HCPCS codes specifically identified as considered not medically necessary are E0935 (continuous passive motion exercise device for use on knee only) and E0936 (continuous passive motion exercise device for use other than knee).
Professional society guidance does not support routine CPM after an uncomplicated primary total knee arthroplasty (TKA). The 2015 AAOS guideline concluded that strong evidence supports that CPM after knee arthroplasty does not improve outcomes, and the APTA guideline (Jette et al., 2020) states that physical therapists should NOT use CPMs for individuals who have undergone primary, uncomplicated TKA (Evidence Quality: High; Recommendation Strength: Moderate). As a result, routine postoperative CPM for primary uncomplicated TKA is not supported and would require specific clinical justification to be considered.
Randomized trials in upper-extremity settings often report early, short-term improvements with CPM that are not maintained long term. For example, Garofalo et al. (2010) reported statistically significant advantages for pain and several ROM measures at about 2.5 months after arthroscopic rotator cuff repair with CPM added to passive self-assisted ROM, but those differences were not present at six months or one year. Smaller randomized studies (Lastayo et al., 1998; Raab et al., 1996) showed no consistent long-term benefit versus manual passive ROM or PT alone, although some subgroup analyses noted transient improvements in pain or ROM.
Summarizing the policy-level determination: CPM devices are considered not medically necessary for any indication. This policy designation applies to both knee-specific and non-knee CPM devices, reflected in the HCPCS codes E0935 and E0936, which are listed as not medically necessary.
Specifically for primary uncomplicated total knee arthroplasty, guideline and review evidence indicate no improvement in clinically important outcomes with routine CPM use. Given the AAOS conclusion of no benefit and the APTA recommendation against CPM in this population, CPM after uncomplicated primary TKA is not supported by evidence and is considered not medically necessary absent clear, documented justification.
Some source chunks summarize randomized controlled trials without explicitly stating a not-medically-necessary (NMN) determination. Those trial summaries report mixed findings: early short-term benefits in pain or ROM in certain studies (e.g., Garofalo et al.) but no sustained long-term advantages in most trials, and heterogeneous results across studies and subgroups.
HCPCS / Billing Codes
Authorization, Documentation, and Billing Impact
Provide clinical justification for CPM requests (e.g., TKA and other indications)
When CPM is requested for cases such as primary uncomplicated total knee arthroplasty or other settings where guidelines recommend against routine use, provide clinical justification including indication, why CPM is expected to add benefit beyond standard care, and operative/treatment details.
- Explain why CPM is necessary despite AAOS/APTA recommendations against routine post‑TKA CPM.
- For other indications (e.g., elbow contracture release, tibial head fracture), include operative details and evidence of failed conservative therapy or ongoing functional limitation.
No explicit prior authorization codes provided
The extract does not list any explicit prior authorization codes or procedural prior authorization process for CPM beyond the NMN determination; no unique prior authorization codes are specified in the policy text.
- No prior authorization codes or explicit prior auth language are present in the cited sections.
No additional prior authorization requirements in extract
The provided extract contains no explicit prior authorization program requirements or affected authorization codes for CPM devices beyond the not‑medically‑necessary coverage position.
No step therapy pathway defined
No step therapy pathways are defined for CPM devices; the policy states CPM is considered adjunctive in literature but declares CPM not medically necessary for any indication.
- Policy does not require progression through alternative therapies prior to CPM because CPM is NMN.
Document prior or concurrent structured physical therapy
When applicable, document prior or concurrent structured physical therapy because many studies evaluated CPM as an adjunct to PT and medical necessity considerations reference PT regimens.
- Specify dates and nature of prior/concurrent PT and how CPM differs from or augments that plan.
No step therapy requirements described
The reviewed chunks contain no step therapy requirements for CPM devices; no formal staged treatment protocols are specified.
Submit appropriate codes and supporting documentation; non‑covered services denied
Submit claims using the most appropriate codes for the service date and include supporting documentation per the applicable benefit plan; services billed with codes not covered by the policy will be denied.
- Use current HCPCS codes as of the date of service; unsupported or non‑covered codes will result in denial.
Document indication, operative details, CPM duration, PT, and follow‑up for THF cases
For tibial head fracture (THF) post‑ORIF cases where CPM was evaluated, documentation should include the indication (THF treated with ORIF), the duration of prescribed CPM use, concurrent physical therapy, preoperative knee ROM, and follow‑up ROM/functional outcomes at specified intervals to support any request.
- Document ORIF operative details, CPM duration (e.g., home CPM for 21 days as studied), PT plan, and ROM/functional follow‑up at 6 weeks and 6 months.
References available to support documentation; no extra DME‑specific paperwork mandated
References and literature citations are provided in the policy and may be used to support clinical documentation or appeals, but the extract does not specify additional DME‑specific documentation requirements (e.g., physician orders or face‑to‑face evaluations).
- Use cited AAOS/APTA guidance and clinical trials when preparing justification, but do not assume extra DME paperwork is required beyond standard claims documentation.
Denial trigger: CPM devices are not medically necessary for any indication
Requests for CPM devices will be denied as not medically necessary for any indication per the policy statement.
CPM after primary uncomplicated TKA is not supported by professional guidance
Use of CPM after primary uncomplicated total knee arthroplasty is not supported by AAOS and APTA guidance and the policy notes this lack of support may influence authorization/denial decisions; provide specific justification if requesting CPM in this setting.
- AAOS: strong evidence that CPM after knee arthroplasty does not improve outcomes.
- APTA: physical therapists should NOT use CPM for primary, uncomplicated TKA.
No explicit authorization/denial triggers found in trial summaries
The cited trial summaries and evidence sections do not specify explicit prior authorization or denial triggers beyond the policy's NMN position; clinical trial descriptions focus on outcomes rather than authorization rules.
No policy changes at annual review; no new denial triggers
Annual review of the policy reported no clinical policy statement changes and did not introduce new denial triggers or authorization requirements.
- Annual review dates: 8/15/2024, 8/15/2025, 8/15/2026 with no clinical policy statement changes.
Clinical Background and Definitions
Continuous passive motion (CPM) is a device-based rehabilitation modality that passively moves a joint through a programmed range of motion. The policy defines CPM devices as not medically necessary for any indication, while the literature summaries included in the record describe device protocols (e.g., Garofalo et al.: CPM used four 30-minute sessions daily for four weeks) and outcomes measured in randomized trials, which informed the policy conclusion that CPM offers inconsistent short-term benefits but no reliable long-term improvement.
When CPM Might Be Considered Medically Necessary
DME medical necessity
Policy determination and supporting evidence
Policy statement supported by literature review and background rationale.
Situations with potential medical necessity
Clinical scenarios where CPM was used with some evidence of benefit:
Kabst et al. (2022) trial findings
Huang et al. (2025) trial description
See rotator cuff and other upper-extremity trials
Upper extremity (rotator cuff) clinical evidence
Clinical trial evidence summaries relevant to upper extremity use (rotator cuff repair):
Garofalo et al. (2010) reported early but not sustained benefit.
Mixed results across smaller trials; no consistent long-term advantage.
Procurement, Rental, and Purchase Considerations
| Equipment | Rule |
|---|---|
| Continuous passive motion (CPM) devices (knee and non-knee models) | |
| Not covered — CPM devices are considered not medically necessary for any indication; HCPCS codes E0935 and E0936 are listed as considered not medically necessary. |
| Equipment | Procurement / place-of-service guidance |
|---|---|
| Home-based CPM devices (described in trials as devices used at home following inpatient initiation) | |
| No payer-specific rental vs. purchase rules specified in the policy extract; clinical trials describe inpatient initiation with continued home use but procurement rules are unspecified. |
| Equipment | Procurement guidance / rental vs purchase |
|---|---|
| Continuous passive motion (CPM) devices (general) — trial-described use protocols | |
| The document and cited trials describe CPM use protocols (duration, sessions, inpatient-to-home use) but do not specify rental versus purchase rules or formal procurement guidance for coverage determinations. |
| Placeholder | Notes |
|---|---|
| (No additional rental/purchase entries) | |
| This table is a placeholder for future rental/purchase rule entries if policy language is added. |
Replacement and Repair Guidance
Required Clinical Documentation
Claims must include supported documentation and appropriate codes
Submit claims with documentation supporting the date of service and appropriate codes; services billed with non-covered codes will be denied as not covered under the policy.
- Ensure billed codes are active on the date of service
- Attach clinical records that justify the billed service
Document operative details, PT, CPM regimen, and follow-up outcomes
For indications where CPM may be considered, document operative procedure details, physical therapy documentation, the prescribed CPM regimen (timing and duration), and follow-up outcomes to support the clinical rationale.
- Operative details (e.g., ORIF for tibial head fracture)
- PT plan and response to prior therapy
- CPM regimen (hours/day, total days)
- Follow-up ROM and functional outcomes
References available but no DME-specific documentation rules provided
The policy provides references and citations that may be used to justify clinical decisions, but it does not define additional DME-specific documentation rules (e.g., supplier orders or face-to-face encounter requirements).
No equipment-specific documentation requirements in extract
The extract contains no equipment-specific documentation requirements such as mandatory supplier paperwork or physician face-to-face visit documentation.
Items and Indications Not Covered
Not covered: All indications for continuous passive motion devices. The policy states that CPM use is considered not medically necessary for ANY indication, and the HCPCS codes listed as not medically necessary are E0935 and E0936. Claims for these services are subject to denial.
Not covered (routine TKA use): Routine postoperative CPM after primary, uncomplicated total knee arthroplasty is not supported by strong evidence. AAOS states CPM does not improve outcomes after knee arthroplasty, and APTA specifically recommends against CPM for individuals after primary, uncomplicated TKA; therefore, routine CPM in this setting is not routinely covered without compelling clinical justification.
No additional DME-specific not-covered items are listed in the provided extracts beyond the device-level exclusion and the specific HCPCS codes identified; the policy does not provide further equipment- or setting-specific not-covered entries in the cited chunks.
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