This policy version was replaced on March 28, 2022. To find the newest version, go to https://www.bluecrossmn.com/providers/medical-policy-and-utilization-management, read and accept the Blue Cross Medical Policy Statement, then select “Blue Cross and Blue Shield of Minnesota Medical Policies.” This will bring up the Medical Policy search screen. Enter the policy number without the version number (last 3 digits).
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.
The CryoCuff™, Cryo Strap™ and the Polar Care Cub™ devices are examples of passive cooling devices. In active devices, a motorized pump circulates cold water and may also provide pneumatic compression. Active cooling devices currently being marketed include but are not limited to the AutoChill® system, Game Ready™ Accelerated Recovery System, Hilotherm® Clinic and Hot/Ice Thermal Blanket.
Heat therapy may also be used for a variety of indications, including pain, muscle spasm, bursitis, and contracture. Water-circulating (mechanical) heat pads are an example of active heat therapy that may be proposed as an alternative to electric heating pads or hot packs.
Combined active heating/cooling device, allows the user to circulate hot or cold water through the system. Combined heating/cooling devices currently being marketed include but are not limited to the VitalWrap™ and Therma™Zone systems.
NOTE: This policy addresses use of cooling or heating devices for pain following surgery or musculoskeletal and soft tissue injury. The policy scope does not include other therapies such as scalp cooling for hair loss during cancer therapy.
The use of active and passive cooling devices for any indication is considered NOT MEDICALLY NECESSARY due to the lack of evidence demonstrating a benefit beyond convenience.
The use of active water-circulating (mechanical) heating pads for any indication is considered NOT MEDICALLY NECESSARY due to the lack of evidence demonstrating a benefit beyond convenience.
The use of active or passive devices that combine cooling and heating for any indication is considered NOT MEDICALLY NECESSARY due to the lack of evidence demonstrating a benefit beyond convenience.
No additional statements.
Blue Cross and Blue Shield of Minnesota medical policies apply generally to all Blue Cross and Blue Plus plans and products. Benefit plans vary in coverage and some plans may not provide coverage for certain services addressed in the medical policies. When determining coverage, reference the member’s specific benefit plan, including exclusions and limitations.
Medicaid products may provide different coverage for certain services, which may be addressed in different policies. For Minnesota Health Care Program (MHCP) policies, please consult the MHCP Provider Manual website.
Medicare products may provide different coverage for certain services, which may be addressed in different policies. For Medicare National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and/or Local Coverage Articles, please consult CMS, National Government Services, or CGS websites.
Note that services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial of claims may result if criteria are not met.
Blue Cross and Blue Shield of Minnesota reserves the right to revise, update and/or add to its medical policies at any time without notice. Codes listed on this policy are included for informational purposes only and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement.
These guidelines are the proprietary information of Blue Cross and Blue Shield of Minnesota. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
Acknowledgements:
CPT® codes copyright American Medical Association® 2022. All rights reserved.
CDT codes copyright American Dental Association® 2022. All rights reserved.
