CurrentBlue Cross Blue Shield - MassachusettsPolicy 721

Patient-controlled end range of motion stretching devices (static progressive and serial)

Policy governs coverage of patient-controlled end range of motion stretching devices (static progressive and serial) for Blue Cross Blue Shield - Massachusetts members across commercial and Medicare products; it specifies investigational status and prior authorization requirements for inpatient services.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyPatient-controlled end range of motion stretching devices (static progressive and serial)

Policy CodePolicy 721

Change TypeNo material change

Effective Date

Next Review DateMay 1, 2025

Key ActionObtain precertification/preauthorization for inpatient services described in this policy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

InvestigationalCoverage stance

Prior auth requiredInpatient requirement

8 codesHCPCS list

InsufficientEvidence conclusion

Coverage Determination

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Not covered (investigational)

Covered when ALL of the following are met:

Investigational stance: Patient-controlled end range of motion stretching devices (static progressive and serial) are considered investigational for the listed Commercial and Medicare products

The evidence is insufficient to determine that static progressive or serial stretch patient-controlled devices improve net health outcome

For outpatient settings, patient-controlled end range of motion stretching devices (static progressive and serial stretch devices) are not a covered service for the following products: Commercial PPO/Indemnity, Medicare HMO BlueSM, and Medicare PPO BlueSM.

The body of evidence for both static progressive and serial (high-intensity) stretch patient-controlled devices includes randomized trials, comparative observational studies, and case series; outcomes reported include range of motion, pain, function, and disease status. Study results are inconsistent across comparators and an improvement in range of motion—when reported—has uncertain clinical significance for functional outcomes. Therefore, the evidence is insufficient to determine that these devices improve net health outcome.

HCPCS and Procedure Codes

Investigational HCPCS CodesHCPCSNot Covered

E1801	Static progressive stretch/patient actualized serial stretch elbow device, extension and/or flexion; includes all components and accessories
E1806	Static progressive stretch wrist device, flexion and/or extension; includes all components and accessories
E1811	Static progressive stretch/patient actualized serial stretch knee device, extension and/or flexion; includes all components and accessories
E1816	Static progressive stretch/patient actualized serial stretch ankle device, flexion and/or extension; includes all components and accessories
E1818	Static progressive stretch forearm pronation supination device; includes all components and accessories
E1831	Static progressive stretch toe device, extension and/or flexion; includes all components and accessories
E1832	Static progressive stretch finger device, extension and/or flexion; includes all components and accessories
E1841	Static progressive stretch/patient actualized serial stretch shoulder device; includes all components and accessories

Provider Requirements and Billing

Denial Risk

Investigational Coverage Stance

For services described in this policy, patient-controlled end range of motion stretching devices (including static progressive and serial stretch devices) are considered investigational for Commercial Members (Managed Care HMO and POS), PPO, Indemnity, and Medicare (HMO BlueSM and Medicare PPO BlueSM) products. Coverage is denied on the basis that these devices are investigational.

Prior Authorization

Prior Authorization Required

Precertification/preauthorization is required for all inpatient services described in this policy. Lack of required prior authorization for inpatient procedures may result in claim denials. For outpatient settings, these services are not covered for Commercial PPO and Indemnity, Medicare HMO BlueSM, and Medicare PPO BlueSM (see policy for product-specific prior authorization rules).

Preauthorization required for all inpatient procedures described in this policy
Outpatient: services described are not covered for Commercial PPO and Indemnity, Medicare HMO BlueSM, and Medicare PPO BlueSM

Billing Rule

Coding and Reporting

Providers must report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes and include applicable modifiers. The codes listed in the policy are informational and not all-inclusive; inclusion or exclusion of a code does not by itself determine coverage.

Report using current CPT, HCPCS, ICD-10, revenue codes and modifiers as applicable
Policy code lists are informational only and not exhaustive

Documentation Required

Conservative Treatment Precedence

Conservative therapies should be attempted prior to consideration of device-based interventions. Standard conservative treatment includes postoperative physical therapy with pressure stretching techniques and home exercises. When rehabilitation fails, options include serial casting, static braces, or dynamic splints that provide low-load prolonged stretch. Document prior conservative management in the medical record.

Conservative therapies: physical therapy, home exercise programs, pressure stretching techniques
If rehabilitation fails: serial casting, static braces, or dynamic splints may be used
Document duration and outcomes of conservative treatment prior to device consideration

Clinical Background

Loss of full joint range of motion commonly follows periarticular surgery and may result from arthrofibrosis, characterized by periarticular fibrosis and scar bands that produce painful loss of end range of motion compared with the contralateral side. Reduced knee range of motion can impair the ability to perform activities of daily living. Patient-controlled stretching devices are home-use devices intended to increase joint range of motion in individuals whose motion and function remain limited despite rehabilitation.

Device and Condition Definitions

inv-11: Static progressive stretch device

DefinitionA device providing low- to moderate-intensity stretching using a crank or ratchet that progressively increases stretch within each session (e.g., Joint Active Systems, Static-Pro).

Typical use settingHome-based use to increase joint range of motion when rehabilitation has failed.

Stretch intensityLow- to moderate-intensity (lower than serial high-intensity devices).

ExamplesJoint Active Systems (JAS); Static-Pro.

Clinical goalImprove joint range of motion to enhance functional outcomes such as activities of daily living.

inv-12: Serial (or serial high-intensity) stretch device

DefinitionA device that alternates periods of higher-intensity stretch and relaxation, typically using hydraulics to provide higher-intensity stretches (e.g., End Range of Motion Improvement [ERMI]).

Typical use settingHome-based device intended for patients with impaired functional status due to decreased range of motion.

Stretch intensityHigher-intensity stretches alternating with relaxation (serial or serial high-intensity).

ExamplesEnd Range of Motion Improvement (ERMI).

Clinical goalProvide higher-intensity, intermittent stretching to improve joint range of motion when conservative rehabilitation has not succeeded.

inv-13: Arthrofibrosis

DefinitionPeriarticular fibrosis and bands of scar tissue causing painful loss of end range of motion compared with the contralateral (normal) side.

Common causeMost common cause of severe postoperative motion loss following periarticular surgery (e.g., total knee arthroplasty, ACL reconstruction).

Functional impactLoss of knee range of motion can impair walking, sitting, rising from a chair, and navigating stairs.

Epidemiology estimateEstimated at least 85,000 major knee surgery patients affected annually in the U.S., with ~21,000 at risk of additional surgery (Stephenson et al., 2010).