Does E0936 require prior authorization?

No, E0936 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

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`E0936`, Continuous passive motion exercise device for use other than knee

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium 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.")

Duration justification: medical record/clinical notes should support the need for up to 3 weeks of CPM therapy when used beyond the usual 7–10 day period; rationale required for any request approaching the 21-day limit. (Policy text: "Although the usual duration of CPM usage is 7 to 10 days, up to 3 weeks of CPM therapy may be considered medically necessary upon individual consideration. Use of the CPM machine beyond 21 days post-op is not supported by the medical literature.")

Clinical documentation should identify the covered surgical procedure or diagnosis that meets the policy's indications (e.g., TKA / revision TKA, arthrofibrosis release, specified cartilage procedures, intra-articular knee fracture repair) and, where applicable, physician orders/instructions indicating non-weight-bearing status or inability to participate in active PT.

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).

6 Active Policies

ANTHEM-CG-DME-52, Continuous Passive Motion Devices in the Home Setting

AETNA-CPB-0010, Continuous Passive Motion (CPM) Machines

BCBSIL-DME101.023, Continuous Passive Motion in the Home Setting

BCBSMT-DME101.023, Continuous Passive Motion in the Home Setting

BCBSNM-DME101.023, Continuous Passive Motion in the Home Setting

BCBSOK-DME101.023, Continuous Passive Motion in the Home Setting

`E0936`, Continuous passive motion exercise device for use other than knee

Prior Authorization

Documentation Required

Key Coverage Criteria

6 Active Policies

Related Codes

Have a follow-up question?

E0936, Continuous passive motion exercise device for use other than knee

Prior Authorization

Documentation Required

Key Coverage Criteria

6 Active Policies

Related Codes

Have a follow-up question?

`E0936`, Continuous passive motion exercise device for use other than knee