Appeal type: Experimental/Investigational
Decision: 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 patients 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 patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2: The patient is a 55-year-old woman who underwent anterior cruciate ligament (ACL) reconstruction in July 2004 using an allograft. Post-operatively a continuous passive motion (CPM) device was utilized. The patients request for reimbursement for use of the CPM device has been denied by the Health Plan.Many surgeons believe CPM therapy is useful in gaining and maintaining motion following surgery. It is a matter of physician preference. If a surgeon feels the device would be beneficial in a particular case, it should be authorized. Numerous studies have shown benefit with CPM. The device has been utilized for more than 20 years for a number of different reasons.In the case of this patient, the device was felt to be of benefit given that she was older than most patients undergoing the procedure. Furthermore, there are no significant risks posed by use of a CPM device. A CPM device was medically reasonable and indicated for the patients successful postoperative rehabilitation. Based upon the information set forth above, I have determined that the equipment 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 3: The patient is a 55-year-old woman who underwent an anterior cruciate ligament (ACL) reconstruction in July 2004. Her surgery was conducted uneventfully. After surgery, the patient underwent a physical therapy program, and concomitant to her physical therapy, she used a continuous passive motion (CPM) device in her home. The Health Plan has denied reimbursement for the CPM device indicating there is not sufficient evidence to conclude that the device is useful and results in clinically better results after ACL surgery. A CPM device is useful in patients after joint surgery who are at high-risk for developing stiffness. Though the literature is some instances supports CPM use after total knee surgery, a study by Ritter, et al. comparing CPM with conventional therapy at a given endpoint (i.e., three and six months) revealed no difference in the outcome. Another article indicates CPM is appropriate for patients undergoing procedures that are high-risk for developing stiffness. There is no evidence ACL surgery performed arthroscopically represents a high-risk procedure for developing arthrofibrosis. Well-designed and randomized controlled trials in peer-reviewed literature regarding the use of CPM are not available. There is insufficient evidence in the peer-reviewed medical literature to conclude that CPM following ACL repair results in significant clinically improved outcomes when compared to individuals who undergo standard post surgical rehabilitation management without CPM.Based upon the submitted records, this patient underwent an appropriate physical therapy program and had a satisfactory outcome. It does not appear the patient benefited greatly from use of the CPM device during her immediate post-operative period. Physical therapy would have been sufficient to allow the patient to achieve satisfactory results, particularly since the records do not demonstrate the patient was at high-risk for developing stiffness. Therefore, I have determined that the equipment 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.