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LCD - CPM

Coverage Criteria:

Written Order Prior To Delivery

Continuous Passive Motion (CPM) device may be considered medically necessary for use postoperatively as an adjunct to conventional physical therapy in the following situations:

  • Under conditions of low postoperative mobility or inability to comply with rehabilitation exercises following a knee arthroplasty or knee arthroplasty revision. This may include patients with complex regional pain syndrome (reflex sympathetic dystrophy), extensive arthrofibrosis or tendon fibrosis, or physical, mental or behavioral inability to participate in active physical therapy. Use of the CPM device must begin within 48 hours of the surgical procedure (or on discharge from facility following the procedure) and may continue for ONLY up to 21 days postoperatively, OR;
  • For up to 6 weeks during the non-weight bearing rehabilitation period following intra-articular cartilage repair procedures of the knee (e.g., microfracture, osteochondral grafting, autologous chondrocyte implantation, treatment of osteochondritis dissecans, repair of tibial plateau fractures), and for reconstruction of the anterior cruciate ligament (ACL).

NOTE: CPM Coverage Criteria may vary depending upon the patient’s insurance plan. The above note criteria is a ‘general’ reference.

Order Requirements

  • CPM Order Form
  • Dr. must be PECOS registered for all Medicare orders.

  1. Patient's Name
  2. Detailed description of item being ordered
  3. Quantity to be dispensed
  4. Prescribed settings
  5. Prescribed frequency of use (hours per day and days per week - ie, 1-7)
  6. Length of Medical Need
  7. Ordering Physician’s NPI
  8. Ordering physician’s legible signature (personally written or electronically signed by the physician, stamps are not accepted by insurance)
  9. Ordering physician’s legible signature date (personally written or electronically signed by the physician, stamps are not accepted by insurance)
  10. Start date of the order – if different than physician signature date.