Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

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. Thompson and colleagues state that the correlation between decreased preoperative range of motion and postoperative risk of poor range of motion has been demonstrated in multiple studies. Prevention and treatment for post-TKA arthrofibrosis includes controlling pain and inflammation as optimally as possible to encourage rehabilitation participation and mobility. A relatively aggressive range of motion program, including but not limited to the formal therapy setting, is critical, requiring a high level of patient commitment and compliance. Nonetheless, overly aggressive protocols to the extent that the exercise precipitates an inflammatory reaction need to be avoided. Thompson and colleagues conclude that reoperative patient education aimed at improving motivation and adherence to appropriate, active protocols has been shown to decrease arthrofibrosis risk. When conservative measures fail, surgical interventions such as manipulation under anesthesia, arthroscopic adhesiolysis, open scar excision and revision knee arthroplasty become potential considerations. The use of continuous passive motion devices has not, however, been demonstrated to improve outcomes following TKA, whether as a general preventive measure or as a treatment after arthrofibrosis has developed. In this case, the patient had 0-90 degrees of preoperative knee range of motion. She underwent therapy in the inpatient, home and outpatient settings, but had persistent stiffness. She ultimately underwent two manipulation under anesthesia procedures as well as an arthroscopic adhesiolysis. Recently, she has had about 100-103 degrees of active knee flexion in the affected leg, while she has been lacking about 22-27 degrees from full active extension. This range of motion is associated with functional impairment and poor patient satisfaction. Nonetheless, it is not expected that a continuous passive motion device will positively impact her course or outcomes in any significant manner. It is not expected to improve her range of motion or function. Therefore, the requested continuous passive motion (CPM) device (HCPCS E0935, E0188) is not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.