Pending Policies - Therapy


Heat and Cold Therapy Devices

Number:THE801.004

Effective Date:11-15-2018

Coverage:

*CAREFULLY CHECK STATE REGULATIONS AND/OR THE MEMBER CONTRACT*

The following heat and cold therapy devices are considered convenience items and not durable medical equipment and therefore are considered not medically necessary:

A device in which ice water is put in a reservoir and then circulated through a pad by means of gravity; or

Motorized water circulating cold pads (e.g., including but not limited to, Polar Care Therapy Pads™, AutoChill™, IceMan™, NanoTherm, Prothermo, and Vascutherm™, etc.); or

Cryogenic machines attached to an insulated disposable blanket; or

Vasopneumatic cryotherapy devices (e.g., including but not limited to, Game Ready ™); or

Non-electric moist or dry heat pads; or

Heat or cold wraps of any type; or

Other similar products.

NOTE: Heat or cold packs (e.g., ice, gel, chemical, etc.), hot water bottles, ice bags, etc., are supplies purchased over the counter without a prescription. Over the counter supplies are generally contract exclusions. Member contract benefit may vary.

Description:

Heat or cold therapy may be used for any of the following:

Post-operatively (e.g., after total knee replacement or hip arthroplasty or anterior cruciate ligament repair), or

Immediately following injury, or

Before or after physical therapy sessions, or

To reduce muscle spasm and improve flexibility of tendons and ligaments, or

Improve circulation, or

Relieve pain, or

Typical athletic cold therapy sessions in order to lower skin temperature and reduce swelling thus decrease bleeding and possibly reduce pain medication requirements.

Methods of administering heat or cold therapy include:

Cryogenic machines attached to insulated blankets, or

Water circulating cold pads (e.g., Polar Care Cold Therapy Pads), or

Cold packs (e.g., ice, gel, chemical, etc.), or

Vasopneumatic cryotherapy devices (e.g., Game Ready ™), (delivers active compression and cold therapy and runs on AC power or optional battery pack), or

Electric and non-electric dry or moist heat pads, or

Heat wraps.

Rationale:

Heat and cold therapy, particularly post-operative cold therapy, are standard treatment modalities that can be provided by a variety of methods. None of these methods has been demonstrated in clinical trials to demonstrate health benefit over others, or over simple compress.

Convenience items are items that are primarily used for the convenience of the patient.

Water circulating cold pads (e.g., Polar Care Cold Therapy Pads) or a cryogenic machine attached to an insulated disposable blanket or similar products are considered convenience items since the same outcome can be achieved with over the counter cold packs.

Heat and cold wraps and packs, ice bags, and hot water bottles are not considered durable medical equipment and can be purchased over the counter without a prescription.

2014 Update

A search of peer reviewed literature through January 2014 identified no new clinical trial publications or any additional information that would change the coverage position of this medical policy.

2015 Update

A search of peer reviewed literature through June 2015 identified no new clinical trial publications or any additional information that would change the coverage position of this medical policy.

2017 Update

A search of peer reviewed literature through March 2017 identified no new clinical trial publications or any additional information that would change the coverage position of this medical policy.

2018 Update

A search of peer reviewed literature through September 2018 identified no new clinical trial publications or any additional information that would change the coverage position of this medical policy.

Contract:

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coding:

CODING:

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.

CPT/HCPCS/ICD-9/ICD-10 Codes

The following codes may be applicable to this Medical policy and may not be all inclusive.

CPT Codes

None

HCPCS Codes

A9273, E0217, E0218, E0236

ICD-9 Diagnosis Codes

Refer to the ICD-9-CM manual

ICD-9 Procedure Codes

Refer to the ICD-9-CM manual

ICD-10 Diagnosis Codes

Refer to the ICD-10-CM manual

ICD-10 Procedure Codes

Refer to the ICD-10-CM manual


Medicare Coverage:

The information contained in this section is for informational purposes only. HCSC makes no representation as to the accuracy of this information. It is not to be used for claims adjudication for HCSC Plans.

The Centers for Medicare and Medicaid Services (CMS) does have a national Medicare coverage position.

A national coverage position for Medicare may have been changed since this medical policy document was written. See Medicare's National Coverage at <http://www.cms.hhs.gov>.

References:

1. Finan, M.A, Roberts, W.S., et al. The effects of cold therapy on postoperative pain in gynecologic patients: a prospective, randomized study. Am J Obstet Gynecol. Feb 1993; 168(2): 542-4. PMID 7679885

2. Daniel, D.M., Stone, M.L., et al. The effect of cold therapy on pain, swelling, and range of motion after anterior cruciate ligament reconstructive surgery. Arthroscopy. Oct 1994; 10(5): 530-3. PMID 7999161

3. Leutz, D.W., H. Harris. Continuous cold therapy in total knee arthroplasty. Am J Knee Surg. Fall 1995; 8(4): 121-3. PMID 8590121

4. Scarcella, J.B., B.T. Cohn. The effect of cold therapy on the post-operative course of total hip and knee arthroplasty patients. Am J Orthop (Belle Mead NJ). Nov 1995; 24(11):847-52. PMID 8581442

5. Konrath, G.A.,T. Lock. The use of cold therapy after anterior cruciate ligament reconstruction. A prospective, randomized study and literature review. Am J Sports Med. Sept-Oct 1996; 24(5): 629-33. PMID 8883683

6. Edwards, D.J., Rimmer, M., et al. The use of cold therapy in the postoperative management of patients undergoing arthroscopic anterior cruciate ligament reconstruction. Am J Sports Med. Mar-Apr 1996; 24(2): 193-5. PMID 8775119

7. Barber, F.A., McGuire, D.A., et al. Continuous-flow cold therapy for outpatient anterior cruciate ligament reconstruction. Arthroscopy. Mar 1998; 14(2): 130-5. PMID 9531122

8. CMS – Cold Therapy- Policy Article – Centers for Medicare & Medicaid Services (2015 revised 2017). Available at <http://www.cms.gov> (accessed – 2018 September 17).

9. CMS – National Coverage Determination (NCD) for Durable Medical Equipment Reference List (280.1) – Centers for Medicare & Medicaid Services. Available at <https://www.cms.gov> (accessed - 2018 September 14).

10. Airaksinen, O.V., Kyeklund, N., et al. Efficacy of cold gel for soft tissue injuries: a prospective randomized double-blinded trial. Am J Sports Med. Sept-Oct 2003; 31(5): 680-4. PMID 12975186

11. Kraeutler, M.J., Reynolds, K.A., et al. Compressive cryotherapy versus ice-a prospective, randomized study on postoperative pain in patients undergoing arthroscopic rotator cuff repair or subacromial decompression. J Shoulder Elbow Surg. Jun 2015; 24(6):854-9. PMID 25825138

Policy History:

DateReason
11/15/2018 Document updated with literature review. Coverage unchanged.
6/1/2017 Document updated with literature review. Coverage unchanged.
9/1/2016 Reviewed. No changes.
9/15/2015 Document updated with literature review. Coverage position is unchanged. The following examples were added: AutoChill™, IceMan™, NanoTherm, Prothermo, and Vascutherm™.
4/15/2014 Literature reviewed. No change.
1/1/2011 The following changes were made: 1) Nonelectric moist heat pads and heat or cold wraps of any type are considered not medically necessary; 2) heat packs, hot water bottles, ice bags, etc., were added to list of examples of supplies purchased over the counter without a prescription; 3) Document title changed from Cold Therapy Devices; 4) CPT/HCPCS code(s) updated.
3/15/2008 Policy reviewed without literature review; new review date only.
11/15/2006 Revised/Updated Entire Document
7/1/2004 Revised/Updated Entire Document
7/5/2004 Codes Revised/Added/Deleted
4/1/1999 Revised/Updated Entire Document
8/1/1998 Revised/Updated Entire Document
5/1/1996 Revised/Updated Entire Document
7/1/1993 Revised/Updated Entire Document
4/1/1993 Revised/Updated Entire Document
7/1/1992 Revised/Updated Entire Document
4/1/1992 Revised/Updated Entire Document
3/1/1991 Revised/Updated Entire Document

Archived Document(s):

Title:Effective Date:End Date:
Heat and Cold Therapy Devices06-01-201711-14-2018
Heat and Cold Therapy Devices09-01-201605-31-2017
Heat and Cold Therapy Devices09-15-201508-31-2016
Heat and Cold Therapy Devices04-15-201409-14-2015
Heat and Cold Therapy Devices01-01-201104-14-2014
Cold Therapy Devices03-15-200812-31-2010
Cold Therapy Devices11-15-200603-14-2008
Cold Therapy07-01-200411-14-2006
Cold Therapy04-01-199906-30-2004
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