Mountain State Medical Policy Bulletin
Section: Durable Medical Equipment
Number: E-48
Topic: Cooling Devices Used in the Home
Effective Date: September 12, 2005
Issued Date: September 12, 2005
Date Last Reviewed: 11/2005

General Policy Guidelines

Indications and Limitations of Coverage

Active cooling devices (E0218, E0236) are considered not medically necessary. Study results suggest that the active cooling device is similar to ice packs, and there is inadequate evidence to demonstrate any benefit beyond ice packs. A participating, preferred, or network provider cannot bill the member for the denied service.

Passive cooling devices (A9270) are not considered durable medical equipment (DME).  Therefore, they are not covered. Scientific literature is insufficient to document that the use of passive cooling systems is associated with a benefit beyond convenience. A participating, preferred, or network provider can bill the member for the denied service.

Description

Cold and/or compression therapy following surgery or musculoskeletal and soft tissue injury is 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.

Passive cooling devices include, but are not limited to, the CryoCuff and the Polar Care Cub.

In active devices, a motorized pump both circulates cold water and may also provide pneumatic compression. Active cooling devices include, but are not limited to, the AutoChill device, the Hot/Ice Thermal Blanket, and the Game Ready Accelerated Recovery System.


NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes

A9270E0218E0236   

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Active cooling devices (E0218, E0236) and passive cooling devices (A9270) are considered not medically necesary.

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

National Blue Cross Blue Shield Association Medical Policy 1.01.26, Cooling Devices Used in the Outpatient Setting, 04/2004

Region A DMERC, LCD L5038, Cold Therapy, 07/01/2004

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Glossary




This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.