Continuous Passive Motion Device denials in California external review

What the reviewers wrote

Where the denial was overturned

A 54-year-old female has requested coverage for past usage of a continuous passive motion (CPM) device for treatment of her knee status post revision of total knee replacement surgery. Findings: The physician reviewer found that based on review of the available records, the use of CPM in the home setting for this patient was indicated and likely to have been beneficial. The supporting reasons for this decision are case specific in that in the preoperative assessment flexion was limited to 100°. On examination at 6-weeks postoperative, the patient’s flexion was 110°. The patient’s pain statement at six-weeks postoperative indicated an improvement in pain levels. In the operative procedure, adhesions were noted in the lateral gutter and suprapatellar pouch and these were released.

Findings: The physician reviewer found that the patient has requested authorization and coverage for a continuous passive motion device. Experts noted `Judet quadricepsplasty is an effective method to treat knee extension contracture and improve knee range of motion (ROM). It should be performed by an experienced orthopedic surgeon and followed by physiotherapy with continuous passive motion (CPM). ` The combined treatment modalities were medically reasonable and resulted in increasing the patient’s range of motion. The utilization of the CPM device in combination with treatment modalities, including physical therapy, home exercises, and medication, represented appropriate adjunctive treatment.

Where the denial was upheld

Physician 1: The patient is a 55-year-old female who underwent reconstruction of her right anterior cruciate ligament (ACL) and torn menial meniscus. The patient’s provider recommended a continuous passive motion (CPM) device for rehabilitation. The Health Plan has denied coverage for the equipment at issue on the basis it is considered investigational.There is insufficient evidence supporting the use of a CPM device in this case. There is no class I data demonstrating superior ACL outcomes with use of a CPM device as opposed to standard rehabilitation modalities. The use of CPM in this case was excessive and not medically warranted. Accordingly, I have determined the equipment at issue was not likely to be more beneficial for treatment of the patient’s medical condition than any available standard therapy.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for continuous passive motion (CPM) device (HCPCS E0935, E0188).Arthrofibrosis, a pathological stiffening of a joint, is incompletely understood but occurs not uncommonly following surgeries such as total knee arthroplasty (TKA). Cheuy and colleagues state that range of motion loss at the knee can be significantly functionally impairing. When these levels of range of motion cannot be achieved, function is compromised. Several preoperative risk factors for development of post-TKA arthrofibrosis have been reported in the literature, including prior knee surgery, smoking, diabetes and limited preoperative knee range of motion, with the latter being the most important factor.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Continuous Passive Motion Device, then check the rights and deadlines that apply to your plan.