CurrentBlue Cross Blue Shield - MassachusettsPolicy 405

Dynamic Low-Load Prolonged-Duration Stretch (LLPS) Devices Policy

Defines medical necessity, covered indications, excluded indications, coding, prior authorization rules, and duration criteria for dynamic LLPS devices (knee, elbow, wrist, finger) for Commercial and Medicare members of Blue Cross Blue Shield Massachusetts.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyDynamic Low-Load Prolonged-Duration Stretch (LLPS) Devices Policy

Policy CodePolicy 405

Change TypeNew policy (8/2024)coding clarification (1/2025)

Effective DateAug 1, 2024

Next Review Date

Key ActionPrecertification/preauthorization is required for inpatient procedures and providers must document prior conservative therapy failure or inability to participate, or persistent functional limitation, and submit an appropriate HCPCS with supporting diagnosis; for continued coverage beyond 4 months document demonstrated improvement in range of motion.

SourceLink

POLICY UPDATE CHANGES

1/2025: Clarified coding information.

8/2024: New medical policy describing medically necessary and investigational indications.

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