Continuous Passive Motion and Mechanical Stretching Devices Form

. Continuous Passive Motion
Continuous passive motion (CPM) devices are designed to aid recovery following surgery or injury to joints or associated tissues. Movement of the joint is provided by a motorized device, which makes it passive rather than active motion. While some CPM devices attach to a bed frame and must be used with the individual lying down, other CPM devices are portable and battery operated for home use. CPM is proposed for use initially following surgery or injury along with standard physical therapy (PT).

Continuous Passive Motion and Mechanical Stretching Devices Effective Date: 02/02/2023 Revision Date: 02/02/2023 Review Date: 02/02/2023 Policy Number: HUM-0323-019 Page: 2 of 10 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. Mechanical Stretching Devices Mechanical stretching devices differ from CPM devices in that they are nonmotorized and are generally proposed as an adjunct treatment to PT and/or exercise. These devices may also be referred to as dynamic devices, which mean they allow some controlled motion; they differ from static devices which do not allow any movement at all, making those an orthotic device. For information regarding static devices, including static AFO (ankle-foot orthosis), please refer to Orthotics Medical Coverage Policy. Mechanical stretching devices may be classified into one of the following three categories: • Low-load prolonged-duration stretch (LLPS) devices, also referred to as dynamic splinting, permit active and passive motion with elastic traction within a limited range and maintain a set level of tension by means of incorporated springs. Examples of LLPS devices include, but may not be limited to: DEROM (ankle, elbow, knee, wrist), Dynasplint, JAS Advance Dynamic, Pro-Glide, SaeboFlex, SaeboReach and Ultraflex.
• Patient-actuated serial stretch (PASS) devices are purported to permit active and passive motion with elastic traction within a limited range, but also provide a low- to high-level load to the joint using pneumatic, hydraulic or tensioning systems that can be adjusted by the individual. Examples of PASS devices include, but may not be limited to: ERMI Elbow Extensionater, ERMI Knee Extensionater, ERMI Knee/Ankle Flexionater and ERMI Shoulder Flexionater. • Static progressive stretch (SPS) devices hold the joint in a set position but are purported to allow for manual modification of the joint angle without exerting stress on the tissue unless the angle is set to the joint’s limitations. While these devices allow for movement (passive or active) within a limited range, the motion is free and does not provide elastic traction. Examples of SPS devices include, but may not be limited to: Joint Active Systems (JAS) Splints (eg, JAS EZ systems [ankle, elbow, finger, knee extension, knee flexion, pronation/ supination, shoulder, thumb and wrist], JAS SPS systems [ankle, elbow, knee, pronation-supination (pro/sup), shoulder, wrist]), Stat-A-Dyne and Static-Pro (elbow, knee, wrist). See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only.

Continuous Passive Motion and Mechanical Stretching Devices Effective Date: 02/02/2023 Revision Date: 02/02/2023 Review Date: 02/02/2023 Policy Number: HUM-0323-019 Page: 3 of 10 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. Coverage Determination For information regarding jaw mobility devices for the treatment of TMJ disorders, please refer to Temporomandibular Joint Disorders Medical Coverage Policy. NOTE: Mechanical stretching devices are NOT orthotic devices. For information regarding orthotics, please refer to Orthotics Medical Coverage Policy. CPM Humana members may NOT be eligible under the Plan for CPM devices (E0935, E0936) for ANY indication including, but not limited to, total knee arthroplasty (TKA) or revision TKA OR injury or surgery of the articular tissues of the shoulder. These are considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition. Note: The criteria for CPM devices are not consistent with the Medicare National Coverage Policy and therefore may not be applicable to Medicare members. Refer to the CMS website for additional information. Mechanical Stretching Devices Humana members may NOT be eligible under the Plan for mechanical stretching devices for ANY indication: • LLPS mechanical stretching devices/dynamic adjustable devices (E1800, E1802, E1805, E1810, E1812, E1815, E1820, E1825, E1830, E1840, L4396) including, but may not be limited to: o AFO (dynamic) (L4396); OR o DEROM (ankle, elbow, knee, wrist); OR o Dynasplint; OR o JAS Advance Dynamic; OR o Pro-Glide; OR o SaeboFlex; OR o SaeboReach; OR o Ultraflex; OR
See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only.

Continuous Passive Motion and Mechanical Stretching Devices Effective Date: 02/02/2023 Revision Date: 02/02/2023 Review Date: 02/02/2023 Policy Number: HUM-0323-019 Page: 4 of 10 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. • PASS devices including, but may not be limited to:
o ERMI Elbow Extensionater; OR o ERMI Knee Extensionater; OR o ERMI Knee/Ankle Flexionater; OR o ERMI Shoulder Flexionater; OR • SPS devices (E1801, E1806, E1811, E1816, E1818, E1821, E1831, E1841) including, but may not be limited to:
o JAS EZ (ankle, elbow, finger, knee extension, knee flexion, pronation/ supination [pro/sup], shoulder, thumb, wrist); OR
o JAS SPS (ankle, elbow, knee, pronation/supination [pro/sup], shoulder, wrist); OR o Joint Active Systems products; OR o Stat-A-Dyne; OR o Static-Pro (elbow, knee, wrist) These are considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition. Background Additional information about joint conditions of the ankle, elbow, finger, knee or shoulder may be found from the following websites: • American Academy of Orthopaedic Surgeons • National Library of Medicine
Medical Alternatives Alternatives to CPM or mechanical stretching devices include, but may not be limited to, the following: See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only.

Continuous Passive Motion and Mechanical Stretching Devices Effective Date: 02/02/2023 Revision Date: 02/02/2023 Review Date: 02/02/2023 Policy Number: HUM-0323-019 Page: 5 of 10 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. • Physical therapy (please refer to Physical Therapy and Occupational Therapy Medical Coverage Policy) Physician consultation is advised to make an informed decision based on an individual’s health needs.
Provider Claims Codes Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure. CPT® Code(s) No code(s) identified CPT® Category III Code(s) No code(s) identified Description Comments Description Comments HCPCS Code(s) E0935 E0936 Description Continuous passive motion exercise device for use on knee only Continuous passive motion exercise device for use other than knee E1399 Durable medical equipment, miscellaneous E1800 E1801 E1802 Dynamic adjustable elbow extension/flexion device, includes soft interface material Static progressive stretch elbow device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories Dynamic adjustable forearm pronation/supination device, includes soft interface material Comments Not Covered Not Covered Not Covered if used to report any device outlined in Coverage Determination section Not Covered Not Covered Not Covered See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only.

Continuous Passive Motion and Mechanical Stretching Devices Effective Date: 02/02/2023 Revision Date: 02/02/2023 Review Date: 02/02/2023 Policy Number: HUM-0323-019 Page: 6 of 10 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. E1805 E1806 E1810 E1811 E1812 E1815 E1816 E1818 E1820 E1821 E1825 E1830 E1831 E1840 Dynamic adjustable wrist extension/flexion device, includes soft interface material Static progressive stretch wrist device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories Dynamic adjustable knee extension/flexion device, includes soft interface material Static progressive stretch knee device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories Dynamic knee, extension/flexion device with active resistance control Dynamic adjustable ankle extension/flexion device, includes soft interface material Static progressive stretch ankle device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories Static progressive stretch forearm pronation/supination device, with or without range of motion adjustment, includes all components and accessories Replacement soft interface material, dynamic adjustable extension/flexion device Replacement soft interface material/cuffs for bi-directional static progressive stretch device Dynamic adjustable finger extension/flexion device, includes soft interface material Dynamic adjustable toe extension/flexion device, includes soft interface material Static progressive stretch toe device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories Dynamic adjustable shoulder flexion/abduction/rotation device, includes soft interface material Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only.

Continuous Passive Motion and Mechanical Stretching Devices Effective Date: 02/02/2023 Revision Date: 02/02/2023 Review Date: 02/02/2023 Policy Number: HUM-0323-019 Page: 7 of 10 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. E1841 L1844 Static progressive stretch shoulder device, with or without range of motion adjustment, includes all components and accessories Knee orthosis (KO), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated L1970 Ankle-foot orthosis (AFO), plastic with ankle joint, custom fabricated L2220 Addition to lower extremity, dorsiflexion and plantar flexion assist/resist, each joint L2780 Addition to lower extremity orthosis, noncorrosive finish, per bar L2820 Addition to lower extremity orthosis, soft interface for molded plastic, below knee section L2830 Addition to lower extremity orthosis, soft interface for molded plastic, above knee section L3730 Elbow orthosis (EO), double upright with forearm/arm cuffs, extension/ flexion assist, custom fabricated L3740 Elbow orthosis (EO), double upright with forearm/arm cuffs, adjustable position lock with active control, custom fabricated Not Covered Not Covered if used to report any device outlined in Coverage Determination section Not Covered if used to report any device outlined in Coverage Determination section Not Covered if used to report any device outlined in Coverage Determination section Not Covered if used to report any device outlined in Coverage Determination section Not Covered if used to report any device outlined in Coverage Determination section Not Covered if used to report any device outlined in Coverage Determination section Not Covered if used to report any device outlined in Coverage Determination section Not Covered if used to report any device outlined in Coverage Determination section See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only.

Continuous Passive Motion and Mechanical Stretching Devices Effective Date: 02/02/2023 Revision Date: 02/02/2023 Review Date: 02/02/2023 Policy Number: HUM-0323-019 Page: 8 of 10 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. L3766 L3900 L3905 L3921 L3973 L4396 Elbow-wrist-hand-finger orthosis (EWHFO), includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment Wrist-hand-finger orthosis (WHFO), dynamic flexor hinge, reciprocal wrist extension/ flexion, finger flexion/extension, wrist or finger driven, custom fabricated Wrist-hand orthosis (WHO), includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment Hand-finger orthosis (HFO), includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment Shoulder-elbow-wrist-hand orthosis (SEWHO), abduction positioning (airplane design), thoracic component and support bar, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment Static or dynamic ankle foot orthosis, including soft interface material, adjustable for fit, for positioning, may be used for minimal ambulation, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Not Covered if used to report any device outlined in Coverage Determination section Not Covered if used to report any device outlined in Coverage Determination section Not Covered if used to report any device outlined in Coverage Determination section Not Covered if used to report any device outlined in Coverage Determination section Not Covered if used to report any device outlined in Coverage Determination section Not Covered References

1. American Academy of Orthopaedic Surgeons (AAOS). Evidence-Based Clinical Practice Guideline. Surgical management of osteoarthritis of the knee. https://www.aaos.org. Published 1996. Updated December 2, 2022. Accessed December 23, 2022.

2. Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). Durable medical equipment reference list (280.1). https://www.cms.gov. Published May 5, 2005. Accessed December 22, 2022. See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only.

   Continuous Passive Motion and Mechanical Stretching Devices Effective Date: 02/02/2023 Revision Date: 02/02/2023 Review Date: 02/02/2023 Policy Number: HUM-0323-019 Page: 9 of 10 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

9. ECRI Institute. Hotline Response (ARCHIVED). Continuous passive motion devices for aiding recovery following cartilage repair surgery. https://www.ecri.org. Published January 2, 2018. Accessed December 7, 2022. ECRI Institute. Hotline Response (ARCHIVED). Continuous passive motion devices for aiding recovery following orthopedic surgery. https://www.ecri.org. Published April 7, 2004. Updated December 26, 2012. Accessed December 7, 2022. ECRI Institute. Hotline Response (ARCHIVED). Dynamic splinting for treating joint stiffness and limited range of motion. https://www.ecri.org. Published May 21, 2014. Accessed December 7, 2022. ECRI Institute. Hotline Response (ARCHIVED). Mechanical stretching devices (ERMI Flexionaters and Extensionaters) for contracture and joint stiffness. https://www.ecri.org. Published March 22, 2011. Accessed February 25, 2013. ECRI Institute. Hotline Response (ARCHIVED). Static progressive stretching devices for restoring range of motion in injured joints. https://www.ecri.org. Published November 4, 2004. Updated December 13, 2011. Accessed December 7, 2022. ECRI Institute. Product Brief (ARCHIVED). Joint Active Systems Progressive Stretch Devices (Joint Active Systems, Inc.) for restoring joint range of motion. https://www.ecri.org. Published March 2, 2015. Accessed December 7, 2022. Hayes, Inc. Evidence Analysis Research Brief (ARCHIVED). Postoperative continuous passive motion for elbow indications. https://evidence.hayesinc.com. Published December 18, 2020. Accessed December 7, 2022.

10. Hayes, Inc. Medical Technology Directory. Continuous passive motion devices for shoulder indications. https://evidence.hayesinc.com. Published May 9,

    2018. Updated May 4, 2022. Accessed December 7, 2022.
          See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only.

    Continuous Passive Motion and Mechanical Stretching Devices Effective Date: 02/02/2023 Revision Date: 02/02/2023 Review Date: 02/02/2023 Policy Number: HUM-0323-019 Page: 10 of 10 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

11. Hayes, Inc. Medical Technology Directory. Continuous passive motion for knee indications: a review of reviews. https://evidence.hayesinc.com. Published March 15, 2018. Updated March 1, 2022. Accessed December 7, 2022.
12. Hayes, Inc. Medical Technology Directory. Mechanical stretching devices for treatment of joint contractures of the extremities. https://evidence.hayesinc.com. Published May 9, 2018. Updated May 9, 2022. Accessed December 7, 2022.
13. Hayes, Inc. Search & Summary (ARCHIVED). Continuous passive motion after foot/ankle surgery. https://evidence.hayesinc.com. Published May 8, 2018. Accessed January 27, 2021.
14. Hayes, Inc. Search & Summary (ARCHIVED). Continuous passive motion (CPM) following microfracture procedure. https://evidence.hayesinc.com. Published June 14, 2011. Accessed February 25, 2013.
15. MCG Health. Continuous passive motion (CPM). 26th edition. https://www.mcg.com. Accessed November 7, 2022.
16. MCG Health. Dynamic joint extension and flexion devices. 26th edition. https://www.mcg.com. Accessed November 7, 2022.
17. MCG Health. Static joint extension and flexion devices. 26th edition. https://www.mcg.com. Accessed November 7, 2022.
18. UpToDate, Inc. Complications of total knee arthroplasty. https://www.uptodate.com. Updated November 2022. Accessed December 22, 2022.
19. UpToDate, Inc. Total joint replacement for severe rheumatoid arthritis. https://www.uptodate.com. Updated November 2022. Accessed December 22, 2022.
20. UpToDate, Inc. Total knee arthroplasty. https://www.uptodate.com. Updated November 2022. Accessed December 22, 2022. See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only.