Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1The patient is a 64-year-old man who underwent rotator-cuff repair. The patient utilized a continuous passive motion (CPM) machine postoperatively. The patient has requested reimbursement for the home-based CPM therapy. The Health Plan has denied the patients request on the basis that CPM therapy is considered experimental.CPM machines have been utilized for nearly 20 years. Though it is more common to use a CPM machine after knee replacement surgery, many surgeons utilize CPM machines after shoulder surgery. Use of a CPM machine by this patient allowed him to avoid significant physical therapy after surgery. Thus, CPM therapy has been effective for the patients postoperative rehabilitation. Therefore, I have determined that the therapy at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 2The patient is a 64-year-old male who has requested reimbursement for home-based continuous passive motion (CPM) therapy. In October 2003, the patient underwent left rotator-cuff repair. The patient underwent CPM therapy for postoperative rehabilitation four times a day for six weeks. The Health Plan indicates that CPM therapy is considered experimental for postoperative rehabilitation.CPM therapy has not been shown to be superior or comparable to postoperative physical therapy rehabilitation. Physical therapy is the standard of care in cases such as this and is a medically reasonable and appropriate alternative to CPM therapy. Review of the medical literature did not provide any evidence that CPM therapy is more efficacious than standard treatment. Therefore, I have determined that the therapy at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3The patient is a 64-year-old male who underwent home-based continuous passive motion (CPM) therapy post rotator-cuff shoulder repair. The patient has requested reimbursement for CPM therapy. The Health Plan indicates that CPM therapy has not been shown to be superior or comparable to physical therapy rehabilitation.Review of the medical literature fails to demonstrate the efficacy of CPM in shoulder rehabilitation. The study by Raab was a prospective, randomized, blinded, controlled study of 26 patients. CPM therapy resulted in no statistically significant benefit for the patients undergoing rotator-cuff repair after three months of CPM therapy. Additionally, the Craig study referenced in the submitted materials had the design flaw that the control group was immobilized 48-72 degrees while the CPM group received CPM therapy shortly after surgery. Hence, it is not surprising that it took the control group longer to regain range of motion.  Furthermore, the Reyes study, which was also referenced in the submitted materials found no significant differences in length of stay, pain medication use or range of motion with CPM therapy in patients post rotator cuff repair. Thus, there is insufficient evidence that CPM therapy was likely to be more effective than standard therapy.Based upon the information set forth above, I have determined that the therapy at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.