CurrentConnectiCarePolicy MG.MM.DM.11

Continuous Passive Motion Devices

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This policy governs home continuous passive motion device coverage for members with a Durable Medical Equipment benefit, including covered postoperative and infant clubfoot indications, medical necessity limits, prior authorization documentation, and applicable procedure and diagnosis codes. Coverage is subject to the member’s benefit plan and the policy’s clinical criteria.

Policy Summary

PayerConnectiCare

PolicyContinuous Passive Motion Devices

Policy CodePolicy MG.MM.DM.11

Change TypeCoverage expansion

Effective DateJun 12, 2026

Next Review DateN/A

Key ActionSubmit clinical evidence showing that the patient meets the CPM coverage criteria for prior authorization review.

SourceLink

POLICY UPDATE CHANGES

The policy added coverage for high-risk procedures associated with arthrofibrosis, including intra-articular major joint reconstruction and fracture repair.

The policy content was transferred to an individual company-branded template.

4Covered indication categories

72 hoursInitiation limit

21 daysMaximum treatment duration

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CurrentConnectiCarePolicy MG.MM.DM.11

Continuous Passive Motion Devices

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Policy Summary

PayerConnectiCare

PolicyContinuous Passive Motion Devices

Policy CodePolicy MG.MM.DM.11

Change TypeCoverage expansion

Effective DateJun 12, 2026

Next Review DateN/A

Key ActionSubmit clinical evidence showing that the patient meets the CPM coverage criteria for prior authorization review.

SourceLink

POLICY UPDATE CHANGES

The policy added coverage for high-risk procedures associated with arthrofibrosis, including intra-articular major joint reconstruction and fracture repair.

The policy content was transferred to an individual company-branded template.

4Covered indication categories

72 hoursInitiation limit

21 daysMaximum treatment duration

Covered Uses and Limitations

Covered Home CPM Indications

Home CPM is covered for members with the Durable Medical Equipment (DME) benefit when the applicable indication below is present. Coverage continues until active physical therapy (PT) participation is achieved, except that active PT is not applicable to infant clubfoot.

ALL of the following

The member has a Durable Medical Equipment (DME) benefit.
At least ONE covered indication applies
- Post anterior cruciate ligament (ACL) or multi-ligament reconstruction, including ACL/MCL, ACL/PCL, or ACL/LCL reconstruction.
  Active PT participation is required for continued home CPM coverage until active PT is achieved.
- Post total knee arthroplasty or revision, as an adjunct to ongoing physical therapy.
  Active PT participation is required for continued home CPM coverage until active PT is achieved.
- Post release of knee arthrofibrosis or adhesive capsulitis requiring manipulation under anesthesia, including high-risk procedures associated with arthrofibrosis during intra-articular major joint reconstruction or fracture repair, such as ORIF of an intra-articular distal femur fracture, ORIF of an intra-articular hip fracture, or post elbow contracture, as applicable.
  Active PT participation is required for continued home CPM coverage until active PT is achieved.
- Infant clubfoot.
  Active PT is not applicable for this indication.

Use Limitations

Home CPM coverage is subject to all applicable limitations below.

ALL of the following

CPM must be initiated within 72 hours of surgery, usually within 24–48 hours.
CPM is typically utilized for 7–10 days and must not exceed 21 days (3 weeks). Continued use beyond 21 days has not been shown to be effective and is not medically necessary.
Continued use of CPM is not medically necessary after 95 degrees of knee flexion, measured by goniometry, is achieved.
CPM is not medically necessary for individuals who are able to participate in an active physical therapy program unless a covered indication listed above specifically applies.
CPM is not medically necessary for non-operatively treated degenerative joint diseases and/or chronic contractures.

CPM is not medically necessary for the treatment of non-operatively treated degenerative joint diseases and/or chronic contractures.

CPM is not medically necessary for any indications other than those listed in this guideline, including but not limited to prophylaxis for thromboembolism, temporomandibular joint disorder, and vertebral use.

Continued use of CPM beyond 21 days (3 weeks) is not medically necessary.

Continued use of CPM after 95 degrees of knee flexion, measured by goniometry, is not medically necessary.

CPM is not medically necessary for individuals who are able to participate in an active physical therapy program unless a listed indication specifically applies.

Procedure and Diagnosis Coding

Covered HCPCS CodesHCPCSCovered

E0935	Continuous passive motion exercise device for use on knee only.
E0936	Continuous passive motion exercise device for use other than knee (Eff. 1/1/2026).

Diagnosis CodesICD-10

M23.50	Chronic instability of knee, unspecified knee.
M23.51	Chronic instability of knee, right knee.
M23.52	Chronic instability of knee, left knee.
M24.561	Contracture, right knee.
M24.562	Contracture, left knee.
M24.569	Contracture, unspecified knee.
M24.661	Ankylosis, right knee.
M24.662	Ankylosis, left knee.
M24.669	Ankylosis, unspecified knee.
Q66.00	Congenital talipes equinovarus, unspecified foot.

1–10 of 64

1/7

CPM initiation

Required initiation windowCPM must be initiated within 72 hours of surgery or procedure.

Usual initiation timingCPM is usually initiated within 24–48 hours of surgery.

Late requestsNo consideration will be given to requests for CPM use more than 72 hours after a procedure.

Typical treatment duration

Typical treatment durationCPM is typically utilized for 7–10 days.

Maximum durationCPM use must not exceed 21 days (3 weeks).

Prior Authorization and Denial Risks

Prior Authorization

Submit medical necessity documentation

The treating physician or primary care provider must submit clinical evidence showing that the patient meets the CPM coverage criteria for prior authorization review.

Documentation Required

Support the prior authorization request

Submit clinical evidence documenting that the patient meets the policy criteria for the requested treatment or procedure. This documentation and information is required for ConnectiCare to properly review the request for prior authorization.

Continuous Passive Motion Devices

A continuous passive motion (CPM) device secures a joint and moves it through a prescribed arc of motion for an extended period to maintain or restore range of motion. CPM devices may be used for multiple joints, including the knee, ankle, jaw, hip, elbow, shoulder, and finger. The policy addresses home CPM use primarily after selected orthopedic procedures and for infant clubfoot, generally while the member is not yet able to participate in active physical therapy.

Key Terms

Arthrofibrosis

ConditionArthrofibrosis is a condition involving abnormal proliferation of fibrous tissue.

LocationThe fibrous tissue proliferates in and around a joint.

Functional impactThe condition impedes proper joint motion and function.

Continuous passive motion (CPM) device

Joint positioningA CPM device secures the affected joint.

MovementThe device moves the affected joint through a prescribed arc of motion.

Duration and purpose

Medical Necessity Criteria

Home CPM Medical Necessity

Home CPM is eligible for members with a DME benefit when one of the listed indications is present and the applicable active physical therapy condition is met.

Eligible indications: Post ACL or multi-ligament reconstruction; post total knee arthroplasty or revision as an adjunct to ongoing physical therapy; post release of knee arthrofibrosis or adhesive capsulitis requiring manipulation under anesthesia, including specified high-risk reconstruction or fracture repair procedures; or infant clubfoot

Active physical therapy participation must not yet be achieved where active PT applies. Active PT is not applicable to infant clubfoot.

Timing and Duration Requirements

Use must comply with all of the following timing, duration, flexion, and indication limitations.

Equipment use limits: Initiate CPM within 72 hours of surgery or procedure; typical use is 7–10 days and must not exceed 21 days (3 weeks); continued use is not medically necessary after 95 degrees of knee flexion measured by goniometry; and CPM must not be used for non-operatively treated degenerative joint diseases or chronic contractures, thromboembolism prophylaxis, temporomandibular joint disorder, vertebral use, or other indications not listed in the guideline.

Required Clinical Documentation

Documentation Required

Submit clinical evidence for home CPM

The treating physician or primary care provider must submit clinical evidence and information demonstrating that the patient meets the CPM medical necessity criteria for prior authorization review. The submission must support the requested home CPM device and applicable indication.

Non-Covered CPM Uses

CPM is not covered when requested more than 72 hours after a procedure, used beyond 21 days, or continued after 95 degrees of knee flexion measured by goniometry. Other non-covered uses include CPM for non-operatively treated degenerative joint disease or chronic contractures, thromboembolism prophylaxis, temporomandibular joint disorder, vertebral use, or indications not listed in the guideline.