CurrentPremera BluecrossPolicy 1.01.540

Continuous Passive Motion in the Home Setting

Defines medical necessity, investigational uses, documentation, coding, and benefit application for continuous passive motion devices used in the home setting, limited to specified knee indications and durations; excludes other conditions as not medically necessary and classifies remote-monitoring/adaptive CPM systems as investigational.

Policy Summary

PayerPremera Bluecross

PolicyContinuous Passive Motion in the Home Setting

Policy CodePolicy 1.01.540

Change TypeAdded investigational classification for remote-monitoring/adaptive CPM; HCPCS E1399 added

Effective DateJun 1, 2026

Next Review Date

Key ActionDocument the type of knee surgery and that the member cannot bear weight after surgery.

SourceLink

POLICY UPDATE CHANGES

Added policy statement that use of devices or systems featuring continuous passive motion with remote monitoring or adaptive capabilities is considered investigational.

HCPCS code E1399 was added to the policy coding list.

Annual literature review updated through January 7, 2026; references added.

2Indications listed as medically necessary (TKA/TKA revision; knee cartilage repair)

6 weeksMax duration for cartilage repair

21 daysMax duration for TKA/TKA revision

Investigational category (remote-monitoring/adaptive systems)

Coverage Summary

This policy addresses Continuous Passive Motion (CPM) in the Home Setting. It defines when CPM is considered medically necessary for specified knee indications and when it is investigational. Key thresholds: CPM following total knee arthroplasty (TKA) or TKA revision is allowable in the home for up to 21 days, and CPM following articular cartilage repair of the knee is allowable during the non-weight-bearing rehabilitation period for up to 6 weeks. The policy is effective 2026-06-01 and was last reviewed on 2026-05-12.

Key policy stats

Medically necessary indications2

TKA home use duration<= 21 days

Articular cartilage repair duration<= 6 weeks

Investigational category count1

Medical Necessity Criteria

Total knee arthroplasty (TKA) or TKA revision — Medical Necessity

Covered when ALL of the following are met:

ALL of the following

ALL of the following
- AND member is unable to ambulate or comply with rehabilitation exercises due to ONE of the following examples
  - Complex regional pain syndrome (reflex sympathetic dystrophy)
  - Extensive arthrofibrosis or tendon fibrosis
  - Physical, mental, or behavioral inability to participate in active physical therapy

ref

Coding

Covered HCPCSHCPCSCovered

E0935	Continuous passive motion exercise device for use on knee only
E0936	Continuous passive motion exercise device for use other than knee

Durable medical equipment, miscellaneous (added)HCPCS

E1399

Durable medical equipment, miscellaneous

Provider Actions & Billing Impact

Documentation Required

Document surgical type and weight-bearing status

Medical record must document the type of knee surgery performed and that the member can't bear weight after surgery.

Documentation Required

Document inability to comply with physical therapy for TKA/TKA revision

For total knee replacement or total knee revision, document that the member is unable to comply with physical therapy because of conditions such as complex regional pain syndrome, extensive arthrofibrosis or tendon fibrosis, or physical/mental/behavioral inability to participate in active physical therapy.

Background and Evidence

CPM devices move or flex a joint without the individual's effort and have been used most often for knee applications, particularly after total knee arthroplasty (TKA) and for ligamentous or cartilage repair. High-quality studies and guidelines (e.g., AAOS, APTA) indicate limited or no benefit in uncomplicated primary TKA, while clinical input and some studies support CPM as an adjunct during the non-weight-bearing rehabilitation period after articular cartilage repair or when patients cannot participate in active physical therapy.

Telerehabilitation or remote-monitoring CPM systems (for example, ROMTech PortableConnect) have been described but evidence on these devices is limited in quality, and the policy classifies use of CPM devices or systems with remote monitoring or adaptive capabilities as investigational. Medicare coverage limits for CPM after TKA (use must begin within 2 days of surgery and be limited to the portion of the 3-week home period) further reflect narrow, indication-specific support for home CPM.

Source	Summary
AAOS guideline (2015)
Strong evidence that CPM after knee arthroplasty does not improve outcomes

Definitions

Continuous Passive Motion (CPM)A device that moves or flexes a joint without the individual's help, used to provide passive motion postoperatively.

Medicare Determinations

Year	Name	Number	Type
{"text":"2005","status":""},{"text":"Durable Medical Equipment Reference List - Continuous Passive Motion Devices","status":""},{"text":"280.1 (NCD referenced)","status":""},{"text":"NCD","status":""}

Revision History

06/01/26material_change_addedLatest

Added policy statement that use of devices or systems featuring continuous passive motion with remote monitoring or adaptive capabilities (e.g., ROMTech PortableConnect) is considered investigational.

06/01/26material_change_addedLatest

HCPCS code E1399 (Durable medical equipment, miscellaneous) was added to the policy coding list.

06/01/26non_material_update

Policy Summary

PayerPremera Bluecross

PolicyContinuous Passive Motion in the Home Setting

Policy CodePolicy 1.01.540

Change TypeAdded investigational classification for remote-monitoring/adaptive CPM; HCPCS E1399 added

Effective DateJun 1, 2026

Next Review Date

Key ActionDocument the type of knee surgery and that the member cannot bear weight after surgery.

SourceLink

On This Page

title":"Total knee arthroplasty (TKA) or TKA revision Medical Necessity"}

Articular cartilage repair of the knee — Medical Necessity

Covered when ALL of the following are met:

Use of CPM following articular cartilage repair procedures (examples: microfracture; osteochondral grafting; autologous chondrocyte implantation; treatment of osteochondritis dissecans; repair of tibial plateau) is considered medically necessary as an adjunct to physical therapy

CPM use is limited to up to 6 weeks maximum and used during the non-weight-bearing rehabilitation period

Other conditions — Not Medically Necessary

Use of CPM in the home setting for all other conditions not listed in this medical policy is considered not medically necessary

Remote monitoring / adaptive CPM systems — Investigational

Use of devices or systems featuring continuous passive motion with remote monitoring or adaptive capabilities (e.g., ROMTech PortableConnect) is considered investigational

Billing Rule

Benefit application under DME

When offered in the home setting, CPM may be adjudicated under durable medical equipment benefits; in other settings CPM may be adjudicated as physical therapy.

E0935
E0936
E1399

Denial Risk

Not medically necessary for other conditions

Claims for home CPM for conditions not specified in the policy (non-TKA and non-articular cartilage knee repairs) are considered not medically necessary and subject to denial.

Documentation Required

Support investigational exclusion for remote-monitoring systems

Use of CPM devices with remote monitoring or adaptive capabilities should be documented as investigational and will not meet medical necessity.

Annual literature review updated through January 7, 2026; references added.