E0936 — Continuous passive motion exercise device for use other than knee
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- Documentation of prior conservative/standard therapy attempts where relevant (for indications where evidence is limited and clinical rationale is required).
- Where the CPM device is used for surgical rehabilitation, documentation must demonstrate that use commenced within 2 days following surgery to meet medical necessity guidelines. (Policy text: "Where the CPM device is used for surgical rehabilitation, the use of this device must commence within 2 days following surgery to meet medical necessity guidelines.")
- Documentation must support that CPM is being used only until the member is participating in an active PT program or until the member begins the weight-bearing phase of recovery, as applicable. (Policy text: "Once the patient is participating in active PT, CPM is no longer medically necessary." and "Once the patient is weight-bearing, CPM is no longer necessary.")
Key Coverage Criteria
- ICD-10 codes covered if selection criteria are met: G90.50 - G90.59 (Complex regional pain syndrome I (CRPS I)).
- ICD-10 codes covered if selection criteria are met: M23.200 - M23.369; M24.80 - M24.9 (Internal derangement of knee and other joints).
- ICD-10 codes covered if selection criteria are met: M72.0 (Palmar fascial fibromatosis [Dupuytren]).
- ICD-10 codes covered if selection criteria are met: M75.00 - M77.9 (Peripheral and other enthesopathies).
- ICD-10 codes covered if selection criteria are met: Numerous options — Musculoskeletal and connective tissue injuries, sequela.
- ICD-10 codes covered if selection criteria are met: M93.20 - M93.29 (Osteochondritis dissecans).
2 Active Policies
AETNA-CPB-0010 — Continuous Passive Motion (CPM) Machines
ANTHEM-CG-DME-52 — CG-DME-52 Continuous Passive Motion Devices in the Home Setting
Related Codes
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