ModifiedPremera BluecrossPolicy 1.01.540

Continuous Passive Motion in the Home Setting

This policy governs coverage of continuous passive motion (CPM) devices used in the home setting after joint surgeries (primarily knee procedures) and specifies when use is medically necessary, investigational, or not medically necessary for Premera Blue Cross members.

Policy Summary

PayerPremera Bluecross

PolicyContinuous Passive Motion in the Home Setting

Policy CodePolicy 1.01.540

Change TypeAdded investigational stanceadded HCPCS E1399

Effective DateJun 1, 2026

Next Review Date

Key ActionVerify member benefits and obtain prior authorization when required; submit documentation showing surgery type and inability to participate in standard rehabilitation.

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.

Added HCPCS code E1399 to policy.

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

Added HCPCS code E1399 to policy.

21 daysmax home use after TKA/TKA revision

6 weeksmax home use after cartilage repair

E0935,E0936,E1399HCPCS codes listed

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investigationalremote/adaptive CPM

Coverage Criteria and Policy Positions

Medically Necessary Indications

Covered when ALL of the following are met

TKA or TKA revision - home CPM

Examples of inability to comply: Member unable to comply with rehabilitation exercises due to: complex regional pain syndrome (reflex sympathetic dystrophy); extensive arthrofibrosis or tendon fibrosis; physical, mental, or behavioral inability to participate in active physical therapy
Examples listed in policy

Articular cartilage repair - home CPM: CPM following articular cartilage repair (e.g., microfracture; osteochondral grafting; autologous chondrocyte implantation; treatment of osteochondritis dissecans; repair of tibial plateau) may be considered medically necessary as an adjunct to physical therapyup to 6 weeks

AND use is during the non-weight-bearing rehabilitation period

Not Medically Necessary

Other conditions: Use of CPM in the home setting for all other conditions not listed in this medical policy

considered not medically necessary

Investigational

Remote monitoring/adaptive CPM devices: Use of devices or systems featuring continuous passive motion with remote monitoring or adaptive capabilities (e.g., ROMTech PortableConnect)

considered investigational

Coverage criteria and limits

Coverage considerations are informed by CMS NCD and professional society guidance; coverage is generally limited and conditional.

Medicare NCD conditions: For patients who have received a total knee replacement, CPM devices are covered when use commences within 2 days following surgery and is limited to the portion of the first 3-week period post-surgery during which the device is used in the patient's home.start within 2 days; use limited to home portion of initial 3 weeks

CMS national coverage determination (2005)

Professional guideline considerations: APTA 2020 recommends not using CPM for primary, uncomplicated TKA; AAOS 2015 concluded combined results show no better outcomes with CPM after knee surgery.N/A

Guideline-based caution against routine use after uncomplicated TKA

Investigational technology: Devices or systems featuring CPM with remote monitoring or adaptive capabilities are considered investigational and not proven for coverage.

Stated coverage positions

High-level coverage stances present in this document excerpt

Investigational for remote/adaptive CPM: Use of devices or systems featuring continuous passive motion with remote monitoring or adaptive capabilities is considered investigational.

Added to policy on 06/01/26

Coverage subject to member benefits: Coverage for medical services is subject to the limits and conditions of the member benefit plan; members/providers should consult the member benefit booklet or contact customer service to determine benefit applicability.

Policy does not apply to Medicare Advantage.

This policy addresses continuous passive motion (CPM) only when provided in the home setting. Use of CPM in the home for indications other than those expressly listed as medically necessary in this policy is excluded and will be considered outside the scope of coverage.

Devices or systems that combine CPM with tele‑rehabilitation, remote monitoring, or adaptive capabilities (for example, ROMTech PortableConnect) are explicitly designated in this policy as investigational. Such technologies are considered not proven for coverage until sufficient evidence demonstrates clinical benefit and will be adjudicated accordingly.

This medical policy and its coverage determinations do not apply to members enrolled in Medicare Advantage plans. Providers and members should consult the member benefit booklet or contact customer service for applicability to Medicare Advantage benefit arrangements.

Use of CPM in the home setting for all other conditions not listed as medically necessary in this policy is considered not medically necessary and is not covered.

The American Physical Therapy Association's 2020 guideline states that physical therapists should not use CPM for patients who have undergone primary, uncomplicated total knee arthroplasty (TKA). This recommendation supports favoring standard rehabilitation over routine CPM following uncomplicated primary TKA.

Use of devices or systems featuring continuous passive motion with remote monitoring or adaptive capabilities is investigational per this policy. The policy was updated to add this explicit investigational designation during the 06/01/26 review.

Billing and Coding

HCPCS codesHCPCS

E0935	Continuous passive motion exercise device for use on knee only
E0936	Continuous passive motion exercise device for use other than knee
E1399	Durable medical equipment, miscellaneous

Included HCPCS codesHCPCSCovered

E1399

Durable medical equipment, miscellaneous

FDA product codesmixed

BXB	FDA product code for CPM devices

HCPCS codes referenced/addedHCPCS

E1399

Durable medical equipment, miscellaneous

Provider Actions, Prior Auth, and Documentation

Billing Rule

DME Adjudication and Documentation

Continuous passive motion (CPM) in the home setting may be adjudicated under the durable medical equipment (DME) benefit. When submitting DME claims, include documentation that supports medical necessity (see documentation callout). If CPM is provided in a non‑home setting it may be adjudicated as physical therapy per the member's plan.

When billed as DME, use appropriate HCPCS; HCPCS E1399 may be used when a more specific code is not available.
Ensure supplier invoices and rental agreements are submitted per payer DME billing rules.

Prior Authorization

Prior Authorization and Benefit Verification

Verify member benefits and obtain prior authorization when required by the member contract before delivery of CPM equipment. Prior authorization requirements and accepted HCPCS codes (including E1399) are subject to plan rules and updates.

Background and Context

Continuous passive motion (CPM) devices mechanically move or flex a joint without the individual's active effort. Historically, CPM has been used most often after knee surgeries—such as total knee arthroplasty, TKA revision, and procedures to repair articular cartilage—to maintain range of motion and reduce adhesions during postoperative rehabilitation. When used at home, CPM is typically applied for limited, procedure‑specific periods as described in this policy.

Definitions

inv-29: Continuous passive motion (CPM) device — definition and common use

DefinitionA device that moves or flexes a joint without the individual's active effort to provide continuous passive movement, most commonly used after knee surgeries.

Typical clinical useUsed postoperatively (often starting in the hospital) to slowly bend the knee and during postoperative rehabilitation to improve range of motion and reduce adhesions.

Usual home durationWhen needed at home after knee surgery it is usually covered for up to 21 days.

Evidence summaryHigh-quality studies show limited benefit for routine knee surgery but possible benefit for select complex knee procedures or patients with prolonged bed rest.

Regulatory noteFDA class I device; exempt from 510(k) requirements.

inv-30: Continuous passive motion device (CPM) — short definition

Policy Revision History

2015-08-11policy_created

New policy added to Durable Medical Equipment section; allowed home use up to 21 days; literature current through June 3, 2015.

2016-06-01annual_review

Annual review approved May 10, 2016; references updated; policy statements unchanged.

2016-10-01interim_update

Interim update approved September 13, 2016 with clinical input and reference added; policy statements unchanged.

Policy Summary

PayerPremera Bluecross

PolicyContinuous Passive Motion in the Home Setting

Policy CodePolicy 1.01.540

Change TypeAdded investigational stanceadded HCPCS E1399

Effective DateJun 1, 2026

Next Review Date

Key ActionVerify member benefits and obtain prior authorization when required; submit documentation showing surgery type and inability to participate in standard rehabilitation.

SourceLink

On This Page

investigational designation

Explicit policy statement added in 2026 review

Confirm whether the member's plan requires prior authorization for CPM as DME.
If prior authorization is required, document rationale referencing the policy criteria and submit operative and therapy records.
Use the member benefit booklet or contact customer service to confirm benefit limits and member cost‑share.

Documentation Required

Required Documentation

Document the medical necessity elements in the medical record and include with any prior authorization or claim submission. Incomplete documentation may result in denial.

Include the type and date of knee surgery and evidence that the member cannot bear weight if applicable.
For TKA or TKA revision, document the specific reason the member cannot participate in active physical therapy (examples: complex regional pain syndrome; extensive arthrofibrosis or tendon fibrosis; physical, mental, or behavioral inability to participate).
Document timing of device use relative to surgery (e.g., initiation within 2 days post‑TKA) and the anticipated duration of use.
Attach physical therapy notes showing inability or failure to participate in standard rehabilitation when CPM is proposed as an adjunct.

Step Therapy

Therapy Sequencing and Adjunct Use

CPM is considered an adjunct to, not a substitute for, standard physical therapy. Coverage is contingent on demonstration that the member is unable to participate in or comply with active rehabilitation.

For primary, uncomplicated TKA, clinical guidelines advise against routine CPM use — prioritize standard post‑operative physical therapy first.
CPM may be considered when the member cannot ambulate or cannot comply with rehabilitation exercises due to documented clinical reasons.
For articular cartilage repair procedures, CPM may be allowed during the non‑weight‑bearing period and for up to 6 weeks as specified in policy.

Denial Risk

Denial Triggers and Plan Limits

Coverage may be denied when policy or plan limits are not met or when device use falls outside defined timeframes or indications.

Use beyond the CMS‑defined limited period after total knee replacement (beyond the home portion of the initial 3‑week period or initiation later than 2 days post‑op) may trigger denial.
Requests for CPM in the home for indications not listed in the policy are considered not medically necessary and may be denied.
If the member's benefit plan does not include DME coverage for CPM, or prior authorization is not obtained when required, the claim may be denied.

Short definitionA device that moves or flexes a joint without the individual's help to provide continuous passive movement.

Common jointMost commonly used on the knee during postoperative rehabilitation.

PurposeMaintain joint motion without active patient participation.

inv-31: Remote-monitoring/adaptive CPM systems — definition and examples (e.g., ROMTech PortableConnect)

DefinitionDevices or systems that add tele-rehabilitation, remote monitoring, or adaptive capabilities to CPM, often transmitting range-of-motion measures and offering active/active-assisted/resistance/passive modes.

Example systemROMTech PortableConnect system, often used with the ROMTech AccuAngle goniometer for transmitted knee extension and flexion measures.

Regulatory noteTelerehabilitation and remote monitoring features of such systems are noninvasive and exempt from premarket notification requirements.

inv-32: Continuous Passive Motion (CPM) — definition in home setting context

Home-setting definitionCPM provided for use in the patient's home as part of postoperative rehabilitation, typically continuing inpatient-initiated therapy into the home setting.

ScopeThis policy addresses CPM only in the home setting and defines coverage and time limits for home use.

Typical initiation and timingCPM usually starts in the hospital and, when used at home after knee surgery, is typically limited to the home portion of the initial postoperative period (commonly up to 21 days for TKA).

inv-33: Remote monitoring or adaptive CPM systems — definition and investigational designation

Investigational designationDevices or systems featuring continuous passive motion with remote monitoring or adaptive capabilities are considered investigational per policy (added 06/01/26).

Policy implicationInvestigational designation means these remote/adaptive CPM systems are not considered proven for coverage under this policy.

Example referencedROMTech PortableConnect is cited as an example of a remote-monitoring/adaptive CPM system in the policy and source text.

Regulatory contextAlthough telerehabilitation features may be exempt from premarket notification, investigational policy stance addresses evidence and coverage, separate from FDA classification.

2017-03-24format_migration

Policy moved into new format with no change to policy statements.

2017-06-01annual_review

Annual review approved May 2, 2017; literature reviewed and HCPCS code E1399 removed; policy statements unchanged.

2017-07-01interim_review

Interim review approved June 22, 2017; wording edits for clarity; policy statements otherwise unchanged.

2018-05-01annual_review

Annual review approved April 18, 2018 with literature updated through January 2018; policy statements unchanged.

2019-06-01annual_review

Annual review approved May 7, 2019 with literature updated through January 2019; policy statements unchanged.

2020-04-01delete_policy

Policy deletion approved March 10, 2020 to be replaced with InterQual criteria effective July 2, 2020.

2020-07-02deletion_effective

Policy deletion became effective July 2, 2020.

2020-11-01policy_reinstated

Policy reinstated effective February 5, 2021; literature reviewed through January 2020; policy statements unchanged.

2021-06-01annual_review

Annual review approved May 4, 2021 with literature review through December 13, 2020; policy statements unchanged.

2022-06-01annual_review

Annual review approved May 9, 2022 with literature review through December 20, 2021; policy statements unchanged.

2023-06-01renumbering

Policy renumbered (recorded in history entries) following administrative updates.

2024-06-01annual_review

Annual review approved May 13, 2024 with literature review through January 17, 2024; policy statements unchanged.

2025-08-01annual_review

Annual review approved July 7, 2025 with literature review through March 19, 2025; policy statements unchanged.

2025-11-07minor_update

Minor update replaced a related policy reference (7.01.78 replaced with 7.01.607).

2026-06-01annual_review_and_material_changeLatest

Annual review approved May 12, 2026; added investigational policy statement for CPM devices with remote monitoring/adaptive capabilities and added HCPCS code E1399 to the policy.