Cpm Machine denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: The patient is a 57-year-old man who underwent an osteotomy for deformity. Postoperatively, a continuous passive motion (CPM) machine was ordered to help regain/maintain knee motion. The patient utilized the CPM machine with good results.Use of a CPM machine was appropriate in the case of this patient. Given the patient’s age and type of surgery required, and given the close proximity to the knee joint, the CPM machine helped to maintain motion at a time when the patient’s pain level was such that he would not have been able to move his knee. The CPM machine has indications other than total joint replacement and this case is an example of appropriate use of the device. Therefore, I have determined that the equipment at issue was likely to be more beneficial for treatment of the patient’s medical condition than any available standard therapy.

The patient’s parent has requested authorization and coverage for continuous passive motion (CPM) machine. Colleagues reported their findings suggested that CPM reduces arthrofibrosis requiring manipulation under anesthesia in pediatric patients after anterior cruciate ligament (ACL) reconstruction. The authors noted that future studies might better define the clinical utility of CPM in rehabilitation after this type of surgery in pediatric patients. Colleagues concluded that CPM has beneficial effects on pain reduction during the first two postoperative days, on knee flexion during the first to the sixth postoperative weeks, and on swelling between the fourth and the sixth postoperative weeks. The authors cautioned that the risk-of-bias scores did not support a high level of evidence for their findings.

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.

Physician 1: The patient is a 46-year-old female who was diagnosed with chronic ACL deficiency, right knee with meniscal pathology in August 2004. She is status post knee arthroscopy with ACL reconstruction, extensive lateral meniscectomy, patellofemoral chondroplasty, and lateral femoral chondroplasty. Her physician has recommended she use a continuous passive motion (CPM) machine for four months following surgery. She is requesting reimbursement for use of the CPM machine. The Health Plan has denied this request indicating CPM therapy is investigational for treatment of the patient’s condition.There is insufficient evidence supporting the use of a CPM machine in this case. There is no class I data demonstrating superior ACL outcomes with use of a CPM machine as opposed to standard rehabilitation modalities.

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 Cpm Machine, then check the rights and deadlines that apply to your plan.