Prior authorization required for LLPS device rental

Rental of LLPS (dynamic) devices for covered anatomic sites requires prior authorization and the request must meet the policy criteria, including timing (subacute window ≥3 weeks and ≤4 months or specified acute post‑operative indication), documented functional limitation, prior nonresponse to other interventions, and provision of adjunctive treatment. Device provision is by rental: initial four weeks; subsequent four‑week periods require documented improvement on reevaluation.

• Timing requirement: ≥3 weeks and ≤4 months after injury/operation for subacute requests
• Rental periods: initial 4 weeks; subsequent 4‑week period requires improvement on reevaluation

Follow Health Plan administrative policies and member benefits

Prior authorization and coverage determinations must follow the Health Plan's administrative policies and the member's benefit documents; coverage decisions and administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents. For Medicaid members, state Medicaid provisions take precedence where they conflict.

• Adhere to Health Plan administrative policies and member benefit documents when requesting authorization
• State Medicaid provisions override this policy when conflicts exist

Adjunctive therapy must accompany device

Approval requires that the requested LLPS device be provided together with adjunctive treatment (for example, a home exercise program or physical therapy). The request must document lack of response to other interventions before approval in the subacute/post‑operative window.

• Adjunctive treatment must be provided with the device (e.g., home exercise program, physical therapy)
• Document prior nonresponse to other interventions, including physical therapy

Include device code and rental request in authorization

Providers must submit clinical information demonstrating that the request meets policy criteria and support medical necessity (see related documentation block). This includes specifying the requested HCPCS code and that the device is being requested as a rental with the applicable rental period.

• Include the specific HCPCS code for the device being requested (see covered code list)
• Indicate rental period requested (initial four weeks or subsequent four‑week period)

Required clinical documentation for authorization

Document the treated anatomic site (toe, knee, elbow, wrist, ankle, or finger), timing relative to injury/operation, the meaningful functional limitation, prior nonresponse to other interventions (including physical therapy), adjunctive treatments provided, and the rental period requested.

• Indication: specify one of the supported sites (toe, knee, elbow, wrist, ankle, or finger)
• Timing: document ≥3 weeks and ≤4 months after injury/operation for subacute requests or the acute post‑operative indication if applicable
• Functional limitation: physician or therapist determination of meaningful limitation
• Prior interventions: documentation of failure to respond to other treatments
• Adjunctive treatment: documentation that home exercise program or physical therapy is provided
• Rental period: initial 4 weeks or subsequent 4‑week period with documented improvement

Review Medicare NCDs/LCDs and member benefit documents

Providers should review applicable Medicare NCDs/LCDs and the member's benefit documents before applying this policy. The Health Plan may change, amend, or withdraw this clinical policy; providers must follow the coverage terms in the member's contract and applicable legal/regulatory requirements.

• Review Medicare NCDs/LCDs for Medicare members prior to applying policy criteria
• Adhere to the member's contract, state and federal requirements, and Health Plan administrative policies

Unsupported device types and indications may be denied

Requests for bi‑directional static progressive stretch (SPS) devices, patient‑actuated serial stretch (PASS) devices, or uses of LLPS for indications not listed in section I are not supported by current research and do not meet the policy's supported indications; such requests may be denied.

• SPS and PASS devices are explicitly not supported by current research per policy
• LLPS use for indications outside section I is not supported

Coverage subject to member contract and Health Plan terms

Coverage decisions and administration of benefits remain subject to all terms, conditions, exclusions and limitations of the member's coverage documents and applicable Health Plan administrative policies and procedures; where state Medicaid provisions conflict with this clinical policy, state provisions take precedence.

• Decisions are governed by the member's coverage documents and Health Plan administrative policies
• State Medicaid manual provisions supersede this policy when conflicts exist