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Date Printed: October 20, 2017: 11:54 AM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

09-E0000-53

Original Effective Date: 10/15/05

Reviewed: 05/23/13

Revised: 11/15/15

Subject: Cooling and Heating Devices Used in the Outpatient Setting

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
Other References Update  

DESCRIPTION:

Heat, cold and/or compression therapy following surgery or musculoskeletal and soft tissue injury has long been accepted in the medical field as an effective tool for reducing inflammation, pain, and swelling. Ice packs and various bandages and wraps are commonly used. In addition, a variety of continuous cooling devices are commercially available and can be broadly subdivided into those providing passive cold therapy and those providing active cold therapy using a mechanical device.

The CryoCuff® and the Polar Care Cub devices are examples of passive cooling devices.

The CryoCuff device consists of an insulated container filled with iced water that is attached to a compressive cuff. When the container is raised, the water fills and pressurizes the cuff. The amount of pressure is proportional to the height of the container. When body heat warms the water, the cooler is lowered and the water drains out. The cooler is then raised above the affected limb and cold water refills the compressive cuff.

The Polar Care Cub unit consists of pads held in place with elastic straps, which may also provide compression. The pads are attached to a built-in hand pump that circulates the water through the pads at the same time as increasing the compression around the joint.

In active devices, a motorized pump both circulates cold water and may also provide pneumatic compression. For example:

The AutoChill® device, which may be used in conjunction with a CryoCuff, consists of a pump that automatically exchanges water from the cuff to the cooler, eliminating the need for manual water recycling.

The Hot/Ice Thermal Blanket is another example of an active cooling device. It consists of 2 rubber pads connected by a rubber hose to the main cooling unit. Fluid is then circulated via the hose through the thermal blankets. The temperature of the fluid is controlled by the main unit and can be either hot or cold.

The Game Ready™ Accelerated Recovery System is an example of an active cooling device combined with a pneumatic component. The system consists of various soft wraps and a computer controlled control unit to circulate the water through the wraps.

The Ice Man Therapy unit is another example of an active cooling device that includes a pad and electric pump to circulate the fluid.

The VitalWrap® System combines hot, cold, and compression therapies into one device for a wide range of applications including post-surgical recovery, sprains, strains and inflammation, pain management, back pain, functional mobility, arthritis and diabetic neuropathy.

POSITION STATEMENT:

Active or passive heating or cooling devices, with or without pneumatic compression, do not meet the definition of medical necessity, as there is insufficient scientific evidence published to conclude that these therapy devices provide any additional therapeutic effect over conventional ice or heat application.

Combination active heating, cooling and compression (cryopneumatic) devices are considered experimental or investigational due to the limited evidence that supports improvement in clinical outcomes; additional studies are needed to permit conclusions regarding the effect of this technology with greater certainty.

BILLING/CODING INFORMATION:

The following codes may be used to describe passive or active cooling devices:

HCPCS Coding:

E0217

Water circulating heat pad with pump (non-covered)

E0218

Water circulating cold pad with pump (non-covered)

E0236

Pump for water circulating pad (non-covered)

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following Durable Medical Equipment Regional Carrier (DMERC) Local Coverage Determinations (LCDs) were reviewed on the last guideline reviewed date: Cold Therapy (L33735), and Heating Pads and Heat Lamps (L33784), located at cgsmedicare.com.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

Durable Medical Equipment (DME), 09-E0000-01 and attached DME Table

OTHER:

Other index terms:

Note: The use of specific product names is illustrative only. It is not intended to be a recommendation of
one product over another, and is not intended to represent a complete listing of all products available.

REFERENCES:

  1. American Academy of Physical Medicine and Rehabilitation. Treating and Preventing Arthritis. Accessed 09/01/09.
  2. Blue Cross Blue Shield Association Medical Policy 1.01.26, Cooling Devices Used in the Outpatient Setting (04/11/13).
  3. Brosseau L, Judd MG, Marchand S, et al. Thermotherapy for treatment of osteoarthtiitis. Cochran Database Systematic Reviews 2003; (4): CD004522.
  4. Centers for Medicare and Medicaid Services (CMS) Region C DMERC Local Coverage Determination (LCD) Medical Policy #L11152, Cold Therapy. Retired 09/30/15.
  5. Centers for Medicare and Medicaid Services (CMS) Region C DMERC Local Coverage Determination (LCD). Heating Pads and Heat Lamps (L33784) (10/01/15).
  6. Centers for Medicare and Medicaid Services (CMS) Region C DMERC Local Coverage Determination (LCD). Cold Therapy (L33735) (10/01/15).
  7. HAYES Alert – Technology Assessment Brief: Gravity-Controlled Cold Therapy Devices for Musculoskeletal and Postoperative Orthopedic Trauma (09/01/04).
  8. HAYES Health Technology Brief. “Cold Therapy Device (Cryo/Cuff™; Aircast Inc.) for Treatment of Musculoskeletal and Postoperative Orthopedic Trauma” (05/25/07).
  9. HAYES Search & Summary. “Active Cooling Devices with Pneumatic Compression for Treatment of Musculoskeletal Injury” (11/13/06).
  10. Robinson VA, Vrosseau L, Casimiro L, et al. Thermotherapy for treating rheumatoid arthritis. Cochran Database of Systematic Reviews 2005; (3): CD002826.
  11. U.S. Food and Drug Administration (FDA) 510(k) K071050 Summary of Safety and Effectiveness, Game Ready Professional Therapy System, Model 550100, Game Ready Pre-programmed Professional Therapy System (07/29/07).
  12. U.S. Food and Drug Administration (FDA) 510(k) K072620 Summary of Safety and Effectiveness, Game Ready Classic System 550550 (10/31/07).
  13. VitalWear VitalWrap® System Specifications. Accessed at https://www.ncmedical.com/item_1523.html.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 05/23/13.

GUIDELINE UPDATE INFORMATION:

10/15/05

New Medical Coverage Guideline.

08/15/07

Scheduled review; reformatted guideline; updated references.

10/15/09

Scheduled review; no change in position statement; updated references.

06/15/13

Revision: Position Statement revised regarding combination active cooling and compression (cryopneumatic) devices; Program Exceptions section updated; references updated.

11/15/15

Revision. Added coverage statement for active/passive heating devices. Revised HCPCS coding section. Updated references.

Date Printed: October 20, 2017: 11:54 AM