Cooling Devices (Passive and Active) Coverage Criteria
Customize your policy alerts
Sign up for all Moda Health policy alerts
Know when Moda Health releases new policies or updates existing guidance.
Monitor payer policy activity
Defines Moda Health coverage for passive and active cooling devices used for postoperative and musculoskeletal/soft-tissue injury care, and the documentation required for prior authorization requests.
No material clinical or coverage changes in this revision.
Coverage and Exclusions
Coverage and Exclusion Criteria
Coverage decisions as defined by Moda Health:
Includes home-setting indications; insufficient evidence that active devices provide greater benefit than least costly ice packs or passive devices.
Moda Health explicitly excludes active cooling devices from coverage for postoperative home use for any indication. The policy lists specific HCPCS codes that will trigger noncoverage when used for active cooling systems, including E0218 (fluid circulating cold pad with pump), E0236 (pump for water circulating pad), and E1399 when used for an active cooling device. Additionally, several pneumatic compressor codes used with cold therapy systems are listed as not covered (for example, E0650, E0651, E0652, and E0655).
Use of active cooling devices in the home setting is considered experimental and investigational and therefore not medically necessary. Moda Health states the available scientific literature is insufficient to show that active devices provide greater benefit compared with standard, less costly ice packs or passive cooling devices, and so active devices are not covered for home postoperative care.
CPT / HCPCS Codes
| E0218 | Fluid circulating cold pad with pump (not covered for active cooling device) |
| E0236 | Pump for water circulating pad (not covered for active cooling device) |
| E1399 | DME, Miscellaneous (Not covered if used for active cooling device) |
| E0650 | Pneumatic compressor; non-segmental home model (not covered for cold therapy units) |
| E0651 | Pneumatic compressor, segmental home model without calibrated gradient pressure (not covered for cold therapy units) |
| E0652 | Pneumatic compressor, segmental home model with calibrated gradient pressure (not covered for cold therapy units) |
| E0655 | Non-segmental pneumatic appliance for use with pneumatic compressor, full arm (not covered for cold therapy units) |
Prior Authorization and Provider Requirements
Prior authorization required with chart notes
Prior authorization is required for cooling device requests and must include provider chart notes documenting the requested procedure or injury; coverage is only applicable when criteria for passive devices are met.
- Submit chart notes from the provider's office documenting the procedure or injury with the prior authorization request.
Preferred therapy: passive cooling devices
Passive cold therapy (ice packs, passive wraps such as CryoCuff or Polar Care Cub) is the preferred and covered therapy for postoperative musculoskeletal care; active, pump-driven devices are not covered in the home setting because they are considered experimental and investigational.
- Use passive cooling devices for postoperative care following musculoskeletal surgery (covered).
- Do not request active cooling devices for home use — they are not covered for any indication.
Required documentation: provider chart notes
Include chart notes from the provider's office documenting the requested procedure or injury with any prior authorization request for cooling devices.
- Provider chart notes must document the procedure or injury that indicates need for the cooling device.
Denial triggers: active cooling devices and pumps
Requests or claims for active cooling devices, associated pumps, and certain pneumatic compressors will be denied as experimental/investigational; specific HCPCS codes are listed as not covered when used for active devices.
DME Medical Necessity Criteria
DME medical necessity
Medical necessity rules for equipment:
Use HCPCS E1399 (DME, Miscellaneous) when applicable for passive cooling devices.
HCPCS codes E0218 (fluid circulating cold pad with pump) and E0236 (pump for water circulating pad) are not covered when used for active cooling devices; active systems lack sufficient evidence of superiority to passive therapy.
Rental, Purchase and Pump Rules
| Item | Rule/Status |
|---|---|
| Cooling devices and pumps | Rule: Policy lists HCPCS codes that may be covered if criteria for passive devices are met and codes that are not covered when used for active cooling devices; no explicit rental vs. purchase rule provided. |
| Covered codes (if criteria met) | E1399 — DME, Miscellaneous (covered if used for passive cooling device); E0218 — Fluid circulating cold pad with pump, any type; E0236 — Pump for water circulating pad. |
| Not covered codes | E0218 — Fluid circulating cold pad with pump (not covered for active cooling device); E0236 — Pump for water circulating pad (not covered for active cooling device); E1399 — DME, Miscellaneous (Not covered if used for active cooling device); E0650 — Pneumatic compressor; non-segmental home model (not covered for cold therapy units); E0651 — Pneumatic compressor, segmental home model without calibrated gradient pressure (not covered for cold therapy units); E0652 — Pneumatic compressor, segmental home model with calibrated gradient pressure (not covered for cold therapy units); E0655 — Non-segmental pneumatic appliance for use with pneumatic compressor, full arm (not covered for cold therapy units). |
Documentation Requirements
Provider chart notes required with prior authorization
Attach provider chart notes documenting the surgical procedure or injury to every prior authorization request for cooling device DME; Moda Health requires these notes to determine whether coverage criteria for passive devices are met.
- Chart notes should clearly document the procedure or injury and the clinical indication for postoperative cold therapy.
- Incomplete or missing chart notes will prevent evaluation and may result in denial of the prior authorization request.
Key Definitions
Clinical Background
Cold and compression therapy are used to reduce pain, swelling, and inflammation after surgery or musculoskeletal/soft-tissue injury. Devices are categorized as passive (non-mechanical cold packs or wraps) or active (mechanical pump-driven circulating systems). Moda Health’s policy supports the clinical role of passive devices for postoperative care following musculoskeletal surgery but finds the evidence for active, pump-driven systems insufficient to demonstrate superior outcomes over passive methods.
Explicitly Not Covered Items
The policy specifically identifies the following categories of equipment as not covered: active cooling devices and their associated pumps (for example, codes E0218 and E0236), E1399 when used for active cooling devices, and certain pneumatic compressors and accessories used with cold therapy systems (E0650, E0651, E0652, and E0655). Requests for these items for home postoperative use will be denied as experimental/investigational.
Replacement Rules
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.