Use of continuous passive motion in the home setting may be considered medically necessary as an adjunct to physical therapy in the following situations:
Under conditions of low postoperative mobility or inability to comply with rehabilitation exercises following a total knee arthroplasty (total knee arthroplasty) or total knee arthroplasty revision. This may include
dystrophy); extensive arthrofibrosis or tendon fibrosis; or physical, mental, or behavioral inability to participate in active physical therapy.
During the non-weight-bearing rehabilitation period following articular cartilage repair procedures of the knee (eg, microfracture, osteochondral grafting, autologous chondrocyte implantation, treatment of osteochondritis dissecans, repair of tibial plateau fractures).
Use of continuous passive motion in the home setting for all other conditions is considered investigational.
