CurrentAmbetter NevadaPolicy CP.MP.144

Mechanical Stretching Devices for Joint Stiffness and Contracture

Customize your policy alerts

Sign up for Ambetter Nevada Policy CP.MP.144 alerts

Get alerted when Policy CP.MP.144 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Defines medical necessity, coding, and coverage stance for mechanical stretching devices (primarily low-load prolonged-duration stretch devices) used to treat or prevent joint stiffness and contracture for members/enrollees of the plan.

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentAmbetter NevadaPolicy CP.MP.144

Mechanical Stretching Devices for Joint Stiffness and Contracture

Customize your policy alerts

Sign up for Ambetter Nevada Policy CP.MP.144 alerts

Get alerted when Policy CP.MP.144 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerAmbetter Nevada

PolicyMechanical Stretching Devices for Joint Stiffness and Contracture

Policy CodePolicy CP.MP.144

Change TypeNo material change

Effective DateN/A

Last ReviewOct 25, 2024

Next Review DateN/A

Key ActionSubmit prior authorization with physician or therapist documentation showing limited ROM causing functional limitation and failure of other interventions for rental requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6Covered joints

4‑wkRental period

ManyHCPCS codes listed

CentenePolicy owner

Coverage Criteria — Mechanical Stretching Devices

Medically necessary criteria for LLPS devices (dynamic splinting)

LLPS device/dynamic stretch device is medically necessary for toe, knee, elbow, wrist, ankle, or finger when ALL of the following are met:

Overall coverage gate: Request meets indication criteria (I.A) AND rental criteria (I.B)

I.A Indication categories: Requested for one of: (1) subacute injury or post-operative period (≥ three weeks and ≤ four months after injury or operation) with persistent joint stiffness or contracture AND all of: (a) limited range of motion poses a meaningful functional limitation determined by the physician or therapist; (b) has not responded to other interventions (including physical therapy); (c) provided with adjunctive treatment (e.g., home exercise program, physical therapy); OR (2) acute post-operative period for members/enrollees who have undergone additional surgery to improve the range of motion of the previously affected joint

Preserve OR between I.A.1 and I.A.2 per source

I.B Rental requirements: Request is for a rental for one of: (1) an initial four weeks; OR (2) a subsequent four-week period where improvement was noted upon reevaluation after the prior four-week periodInitial 4 weeks; subsequent 4-week periods require documented improvement on reevaluation

Rental-only coverage

Not supported / comparative effectiveness

Devices and indications not supported by current research:

Not supported list: LLPS for any indication not noted in section I; Bi-directional static progressive stretch (SPS) devices; Patient-actuated serial stretch (PASS) devices

Descriptive comparative-effectiveness stance per policy II

The following HCPCS codes are listed in the policy as not supported for coverage under the “do not support coverage criteria” group: E1399, E1801, E1806, E1811, E1816, E1818, E1831, E1832, E1840, and E1841.

Coverage determinations in this clinical policy are intended to guide medical necessity decisions but do not replace the member’s contract. All coverage is subject to the terms, conditions, exclusions and limitations of the member’s coverage documents (e.g., evidence of coverage, certificate of coverage, policy) and to applicable state and federal requirements; where state Medicaid provisions conflict, state Medicaid takes precedence.

The policy states that current research does not support use of LLPS devices for any indication not listed in section I. Additionally, the policy identifies that bi-directional static progressive stretch (SPS) devices and patient-actuated serial stretch (PASS) devices are not supported over other currently available alternatives.

Coding and Billing

HCPCS codes supporting coverage criteriaHCPCSCovered

E1800	Dynamic adjustable elbow extension/flexion device, includes soft interface material
E1802	Dynamic adjustable forearm pronation/supination device, includes soft interface
E1803	Dynamic adjustable elbow extension only device, includes soft interface material
E1804	Dynamic adjustable elbow flexion only device, includes soft interface material
E1805	Dynamic adjustable wrist extension/flexion device, includes soft interface material
E1807	Dynamic adjustable wrist extension only device, includes soft interface material
E1808	Dynamic adjustable wrist flexion only device, includes soft interface material
E1810	Dynamic adjustable knee extension/flexion device, includes soft interface material
E1812	Dynamic knee, extension/flexion device with active resistance control
E1813	Dynamic adjustable knee extension only device, includes soft interface material

1–10 of 21

1/3

HCPCS codes that do not support coverage criteriaHCPCSNot Covered

E1399	Durable medical equipment, miscellaneous
E1801	Static progressive stretch elbow device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories
E1806	Static progressive stretch wrist device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories
E1811	Static progressive stretch knee device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories
E1816	Static progressive stretch ankle device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories
E1818	Static progressive stretch forearm pronation/supination device, with or without range of motion adjustment, includes all components and accessories
E1831	Static progressive stretch toe device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories
E1832	Static progressive stretch finger device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories
E1840	Dynamic adjustable shoulder flexion/abduction/rotation device, includes soft interface material
E1841	Static progressive stretch shoulder device, with or without range of motion adjustment, includes all components and accessories

inv-08: Post-operative/request timing — Subacute and acute timing

Subacute timingRequest in the subacute injury or post-operative period: ≥ 3 weeks and ≤ 4 months after injury or operation

Acute additional surgeryAllowed in the acute post-operative period when member has undergone additional surgery to improve ROM of the previously affected joint

Overall requirementIndication must include persistent joint stiffness or contracture and meet all other clinical criteria per policy I.A

inv-09: Rental duration

Initial rental periodInitial rental authorized for four weeks

Subsequent rental periodsSubsequent rentals authorized in four-week increments only if improvement was noted on reevaluation after the prior four-week period

Provider Actions, Prior Authorization & Documentation

Prior Authorization

Prior authorization required for rental of LLPS devices

Rental requests for low-load prolonged-duration stretch (LLPS) or dynamic stretch devices for covered joints must be submitted with the clinical documentation described in sections I.A and I.B of the policy and are subject to prior authorization.

Applies to HCPCS codes listed as supporting coverage (e.g., E1800, E1802, E1803, E1804, E1805, E1807, E1808, E1810, E1812, E1813, E1814, E1815, E1820, E1822, E1823, E1825, E1826, E1827, E1828, E1829, E1830, E1832).

Prior Authorization

Confirm prior authorization with Health Plan

Prior authorization requirements vary by Health Plan and are subject to plan-level administrative policies and applicable state and Medicare coverage determinations; providers must confirm PA requirements with the member's Health Plan before submitting requests.

Confirm plan-specific PA rules, effective dates, and any state Medicaid exceptions prior to ordering or renting devices.

Background and Rationale

Joint contracture is defined as a reduction in joint range of motion due to structural changes in soft tissues; prolonged immobilization after surgery or trauma is a common cause. Mechanical stretching devices (including LLPS/dynamic stretch, SPS, and PASS) are used post-operatively or after injury as adjuncts to therapy, and the policy frames their use in the context of timing, functional limitation, prior interventions, and available evidence.

Definitions

inv-19: LLPS (low-load prolonged-duration stretch)

DefinitionDevices that permit resisted active and passive motion using elastic traction and maintain a set level of tension by means of incorporated springs

Also known asAlso referred to as dynamic splinting or dynamic stretch devices

Typical useUsed to provide prolonged low-load stretch post-operatively or after injury to reduce contracture and improve ROM

inv-20: SPS (static progressive stretch)

DefinitionDevices that hold the joint in a set position but allow manual modification of the joint angle and may allow active motion without resistance (inelastic traction)

MechanismProvides static progressive adjustments rather than continuous elastic tension

Policy Summary

PayerAmbetter Nevada

PolicyMechanical Stretching Devices for Joint Stiffness and Contracture

Policy CodePolicy CP.MP.144

Change TypeNo material change

Effective DateN/A

Last ReviewOct 25, 2024

Next Review DateN/A

Key ActionSubmit prior authorization with physician or therapist documentation showing limited ROM causing functional limitation and failure of other interventions for rental requests.

SourceLink

On This Page

Rental-only coverageCoverage is for rental of device (not purchase) per policy I.B

Step Therapy

Step requirement: failure of other interventions

Device rental is expected only after failure to respond to other interventions, including physical therapy, per criteria I.A.1.b; document prior interventions and lack of response.

Document that the member has undergone other interventions (e.g., physical therapy) and did not respond prior to requesting LLPS device rental.

Note

Confirm policy gates and plan administrative requirements

Provider must confirm that the request meets all policy coverage gates (indication and rental criteria) and include any additional clinical details required by the Health Plan to avoid administrative denials.

Ensure indication meets I.A (subacute or specified acute post-op indications) and rental meets I.B (initial 4 weeks or subsequent 4-week period with documented improvement).
Verify plan-level administrative requirements and state/regulatory mandates before submission.

Documentation Required

Required clinical documentation

Provide physician or therapist documentation that limited range of motion poses a meaningful functional limitation, plus documentation of prior interventions (including physical therapy) and adjunctive treatments (home exercise program, physical therapy) as described in the policy.

Document objective findings of ROM limitation and how it produces functional impairment.
Include records showing prior interventions and lack of response, and that adjunctive treatments accompany the requested device.

Documentation Required

Documentation and regulatory alignment

Follow the Health Plan's coverage determinations and applicable state Medicaid, Medicare NCD/LCD, and regulatory requirements; maintain documentation supporting medical necessity per the Health Plan's criteria.

Adhere to plan evidence of coverage and state Medicaid provisions where they take precedence.
Retain records that demonstrate compliance with the policy criteria and any applicable legal/regulatory requirements.

Denial Risk

Noncompliant indications or rental requirements risk denial

Requests that do not meet the policy's indication criteria (I.A) or rental requirements (I.B) risk denial; ensure timing, documented functional limitation, prior intervention failure, and adjunctive treatment are met and recorded.

I.A requirements: subacute timing (≥3 weeks and ≤4 months) or specified acute post-op indication, documented meaningful functional limitation, failure of other interventions, and adjunctive treatment.
I.B requirements: request must be for an initial four-week rental or a subsequent four-week rental with documented improvement on reevaluation.

Denial Risk

Denial risk from plan terms and legal/regulatory conflicts

Coverage and benefit administration are subject to all terms, conditions, exclusions and limitations of the member's coverage documents and to state and federal requirements; conflicts with state Medicaid provisions mean state rules take precedence.

Verify member-specific contract terms and state Medicaid rules before proceeding.
Plan-level administrative policies and procedures may further restrict coverage.

Evidence noteSPS evidence available for some joints (e.g., elbow) but SPS devices listed as not supported over alternatives in policy II.B

inv-21: PASS (patient-actuated serial stretch)

DefinitionDevices permitting resisted active and passive motion using adjustable pneumatic or hydraulic systems that can be adjusted by the patient

Adjustment and fittingTypically require patient adjustment and custom fitting; pneumatic systems used for extensionators and hydraulic for flexionators

Policy stancePASS devices are not supported over other currently available alternatives per policy II.C

inv-22: Dynamic splinting / static progressive splinting

ScopeMechanical devices designed to provide sustained or progressive stretching to improve joint range of motion and reduce contracture

IncludesEncompasses dynamic splinting and static progressive splinting devices used for post-operative or post-injury joint stiffness

Evidence summaryPeer-reviewed studies are limited; best evidence exists for LLPS at knee, elbow, wrist and for specific finger/extensor tendon injuries; multiple clinical studies and reviews referenced