CurrentEmblemHealthPolicy MG.MMDM.11bC12

Continuous Passive Motion Devices

Clinical coverage guideline for home continuous passive motion devices (CPM) under EmblemHealth Durable Medical Equipment benefits, including indications, limitations, coding, and diagnoses relevant to authorization decisions.

Policy Summary

PayerEmblemHealth

PolicyContinuous Passive Motion Devices

Policy CodePolicy MG.MMDM.11bC12

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit treating physician documentation with the preauthorization request demonstrating the specific covered indication and timing of initiation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

21 daysmaximum CPM use duration considered medically necessary post-op

72 hoursCPM must be initiated within (post-surgery)

95°knee flexion threshold after which CPM is not medically necessary

E0935HCPCS code for knee-only CPM device

Coverage Criteria for Home Continuous Passive Motion (CPM)

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inv-01: Covered indications

Members with the DME benefit are eligible for home CPM coverage until active PT participation is achieved for any of the following:

Covered indications list: Post anterior cruciate ligament (or multi-ligament) reconstruction (e.g., ACL/MCL, ACL/PCL, ACL/LCL); Post total knee arthroplasty or revision as an adjunct to on-going physical therapy; Post release of arthrofibrosis/adhesive capsulitis of the knee requiring manipulation under anesthesia; Infant clubfoot (active PT not applicable)

Coverage is until active PT participation is achieved

inv-02: Limitations

Coverage is subject to the following conditions — all must be met:

Initiation and duration: CPM must be initiated within 72 hours of surgery (usually within 24-48 hours) and is typically utilized for 7-10 days; total use must not exceed 21 days.initiate ≤72 hours; duration ≤21 days

Continued use beyond 21 days is not considered medically necessary

Range of motion threshold: Continued use of CPM is not medically necessary after 95 degrees of knee flexion (measured by goniometry) is achieved.knee flexion ≥95°

Active PT availability: CPM is not medically necessary for individuals who are able to participate in an active physical therapy program unless the indication listed above specifically applies.

CPM is not considered medically necessary for the treatment of non-operatively treated degenerative joint disease or for the management of chronic contractures. Requests for CPM that are not one of the listed covered indications will not meet medical necessity, and CPM should not be used as a substitute when active physical therapy participation is possible. Additionally, CPM is not authorized for indications outside those specified in the policy (see NOT COVERED).

Continued use of CPM beyond the policy limits is not medically necessary. Specifically, CPM must be initiated within 72 hours of surgery and is typically used for 7–10 days, with use not to exceed 21 days. Continued CPM beyond 21 days has not been shown to be effective. Continued CPM is also not medically necessary once the patient has achieved 95 degrees of knee flexion by goniometry. No consideration will be given for CPM requests initiated more than 72 hours after a procedure.

Procedure and Diagnosis Coding

Procedure / HCPCSHCPCSCovered

E0935

Continuous passive motion exercise device for use on knee only

Covered ICD-10 Diagnoses (excerpt)ICD-10Covered

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
M24.69	Ankylosis, other specified joint
M24.661	Ankylosis, right knee
M24.662	Ankylosis, left knee
M24.669	Ankylosis, unspecified knee

1–10 of 37

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inv-07: Knee flexion threshold — continued CPM not medically necessary after 95°

ThresholdContinued CPM is not medically necessary after 95 degrees of knee flexion (measured by goniometry).

Measurement methodKnee flexion to be measured by goniometry to determine 95° threshold.

Applies toPostoperative knee CPM use (policy limitation).

inv-08: Initiation window — CPM must be initiated within 72 hours of surgery (usually 24-48 hours)

Initiation windowCPM must be initiated within 72 hours of surgery (typically within 24–48 hours).

Late initiationRequests for CPM initiated more than 72 hours after surgery will not be considered.

DocumentationPreauthorization should document timing of initiation relative to the procedure.

inv-09: Maximum duration — CPM use not to exceed 21 days

Maximum durationCPM use is typically 7–10 days and must not exceed 21 days (3 weeks).

Clinical rationaleContinued use beyond 21 days has not been shown to be effective and is not medically necessary.

Coverage implicationContinued CPM beyond 21 days will be considered not medically necessary and not covered.

Provider Actions, Prior Authorization & Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for home continuous passive motion (CPM) devices for the knee. Requests must include documentation that the member meets one of the covered indications and that the member is eligible under the durable medical equipment (DME) benefit. Requests submitted without the required clinical information will not be properly reviewed and may be denied.

Affected code: HCPCS E0935 (knee-only device)

Documentation Required

Documentation Requirement

The treating physician or primary care provider must submit clinical documentation supporting that the member meets the policy criteria for CPM use. Requests submitted without clinical documentation demonstrating the member meets the criteria will not be properly reviewed and may be denied.

Include operative reports, progress notes, goniometric measurements of knee flexion, and physical therapy records as applicable.

Documentation Required

Required Clinical Evidence

Clinical evidence must demonstrate that the member meets one of the covered indications for home knee CPM and justify the need prior to initiation or continued use. EmblemHealth requires submission of relevant clinical notes to support the specific indication (for example, ACL or multi-ligament reconstruction, total knee arthroplasty or revision as an adjunct to ongoing PT, post release of arthrofibrosis requiring manipulation under anesthesia, or infant clubfoot).

Operative report and diagnosis must match a covered indication.
If used as an adjunct to PT after TKA/revision, provide documentation of concurrent PT plan and rationale for CPM use.

Denial Risk

CPM Limited Pending Active Physical Therapy

Coverage for home CPM is limited and temporary pending active participation in an active physical therapy program. Continued use of CPM is not considered medically necessary for individuals who are able to participate in active PT, and ongoing CPM beyond the point when active PT is being performed may be denied.

CPM is typically utilized for 7–10 days and not to exceed 21 days (3 weeks).
Continued use beyond 21 days or after achieving ≥95° knee flexion (goniometry) is not medically necessary.

Medical Necessity Criteria for CPM

inv-19: DME Medical necessity

CPM is medically necessary for home DME benefit when ALL of the following apply:

DME medical necessity criteria: Member has one of the covered indications; CPM is initiated within 72 hours of surgery; intended duration is within policy limits (typically 7-10 days, not to exceed 21 days); continued knee flexion is less than 95 degrees and the member is not able to participate in active physical therapy (unless the covered indication specifies otherwise).initiate ≤72 hours; duration ≤21 days; knee flexion <95°

Submit treating physician documentation with the preauthorization request demonstrating the specific covered indication and timing of initiation.

Equipment	HCPCS	Rental vs Purchase
Continuous passive motion device (knee)	E0935 — Continuous passive motion exercise device for use on knee only	Rental (covered under the home DME benefit) — device billed as a rental per policy; purchase not indicated in policy for knee-only CPM.

Required Documentation for Preauthorization

Documentation Required

Attach treating physician documentation with preauthorization

Include treating physician documentation with the preauthorization request that demonstrates the specific covered indication and the timing of CPM initiation relative to the surgical procedure.

Documentation should show the date/time of surgery and the date CPM was initiated to confirm initiation within the 72‑hour window.
Attach clinical evidence that the member meets one of the policy's listed indications.

Background

Continuous passive motion (CPM) devices are motorized devices that passively move a joint through a controlled range of motion to maintain or restore joint range of motion. In the post-operative setting the policy frames CPM as a temporary home DME adjunct intended to be used until a member can participate in active physical therapy. Typical use is initiated soon after surgery (usually within 24–48 hours, and no later than 72 hours), for a short course (commonly 7–10 days), and must not exceed 21 days total.

Definitions

inv-16: Arthrofibrosis — definition of arthrofibrosis

DefinitionArthrofibrosis is a condition characterized by abnormal proliferation of fibrous tissue in and around a joint that impedes proper motion and function.

Clinical effectResults in limited joint range of motion and impaired function.

Relevance to CPMPost-release of arthrofibrosis requiring manipulation under anesthesia is listed as a covered indication for CPM use until active PT participation.

inv-17: Continuous passive motion (CPM) devices — definition and joints applicable

DefinitionContinuous passive motion (CPM) devices are devices used for the maintenance or restoration of joint range of motion (ROM) by passively moving the joint.

Applicable jointsCPM devices are available for multiple joints including knee, ankle, jaw, hip, elbow, shoulder and finger.

Common useUsed postoperatively or for specific indications to preserve or restore ROM until active physical therapy participation is achieved.

inv-18: Intra-articular fracture — definition

DefinitionAn intra-articular fracture is a fracture involving the portion of bone that is enclosed by cartilage and part of a joint.

ImplicationBecause the fracture extends into the joint surface, it can affect joint function and may be relevant to postoperative rehabilitation decisions.

Relation to policyRecognized in definitions section for clinical context; may be a relevant diagnosis in CPM consideration when associated with covered indications.

Policy Summary

PayerEmblemHealth

PolicyContinuous Passive Motion Devices

Policy CodePolicy MG.MMDM.11bC12

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit treating physician documentation with the preauthorization request demonstrating the specific covered indication and timing of initiation.

SourceLink

On This Page

OpenPayer

Continuous Passive Motion Devices

Coverage Criteria for Home Continuous Passive Motion (CPM)

Procedure and Diagnosis Coding

Provider Actions, Prior Authorization & Documentation

Medical Necessity Criteria for CPM

Rental / Purchase Rules for CPM Devices

Required Documentation for Preauthorization

Background

Definitions

Not Covered