CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Patient-controlled End Range of Motion Stretching Devices (Static Progressive and Serial Stretch Devices)

This policy governs coverage and medical necessity determinations for patient-controlled end range of motion stretching devices (static progressive stretch and serial/serial stretch devices) for members of Blue Cross Blue Shield - Rhode Island, including BlueCHiP for Medicare and commercial products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

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

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 10, 2015

Next Review Date

Key ActionVerify member benefits and coverage determinations; prior authorization is not applicable but devices listed are not covered or are not medically necessary per this policy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not medically necessaryCommercial products coverage stance

Not coveredBlueCHiP for Medicare coverage stance

7 codesNot covered / not medically necessary

15–30 min/sessionTypical device usage

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Functional knee ROM threshold

Coverage Determinations

Coverage determinations

Coverage stance by product

BlueCHiP for Medicare stance: Patient-controlled end range of motion stretching devices are not covered as the evidence is insufficient to determine the effects of the technology on health outcomes.

Commercial products stance: Patient-controlled end range of motion stretching devices are considered not medically necessary as the evidence is insufficient to determine the effects of the technology on health outcomes.

Functional ROM threshold (context): Functional knee range of motion of approximately 110 degrees is cited as a threshold necessary for common activities of daily living and is used as a measure of treatment success for individual patients.~110 degrees

Contextual outcome measure; not an authorization criterion.

The following HCPCS codes for static progressive stretch devices are not covered for BlueCHiP for Medicare and are not medically necessary for Commercial Products: E1801, E1811, E1806, E1816, E1831, E1818, E1841. Each code describes a static progressive stretch device for a specific joint and includes all components and accessories as listed in the coding section.

For Commercial Products, patient-controlled end range of motion stretching devices are considered not medically necessary because the evidence is insufficient to determine the effects of the technology on health outcomes. This stance applies to static progressive stretch devices identified by HCPCS codes E1801, E1811, E1806, E1816, E1831, E1818, and E1841, which are explicitly listed as not medically necessary.

Codes and Functional Thresholds

Not covered / Not medically necessary HCPCS codesHCPCSNot Covered

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

Functional knee ROM threshold — ADLs benchmark

Functional knee ROM thresholdApproximately 110 degrees considered necessary to perform common activities of daily living (stair negotiation, rising from low chair/commode, entering/exiting a car, tying shoes)

Use as treatment success measureThe 110° threshold is used as a measure of treatment success for individual patients with limited knee ROM

Related abnormal thresholdsExtension deficit of 6°–10° or flexion deficit of 16°–25° compared with the noninvolved knee is categorized abnormal; larger deficits are severe

Provider Requirements and Billing Notes

Prior Authorization

Prior Authorization / Benefit Note

Prior authorization: Not applicable. Providers should confirm any prior authorization requirements with the member’s benefit plan before ordering or billing for patient‑controlled end range of motion stretching devices.

Check member-specific requirements prior to service

Documentation Required

Benefit Verification

Benefits and coverage vary by contract. Refer to the member’s Benefit Booklet, Evidence of Coverage, or Subscriber Agreement to determine whether services or devices are covered, excluded, or considered not medically necessary for that member.

Verify eligibility, plan benefits, and any medical necessity requirements before scheduling or billing

Background and Clinical Context

Loss of full range of motion (ROM) after joint surgery—commonly due to arthrofibrosis—can substantially impair the ability to perform activities of daily living. Functional deficits following procedures such as total knee arthroplasty or ligament reconstruction may limit tasks that require deep knee flexion or full extension. When conservative rehabilitation fails, options historically include serial casting, static braces, dynamic splints, manipulation under anesthesia, and arthroscopic or open lysis of adhesions; patient-controlled stretching devices are intended to increase end-range ROM through repeated stretching sessions but have not demonstrated consistent improvements in these functional outcomes in the evidence base.

Device Definitions

Static progressive stretch (SPS) devices — description

Device mechanismStatic progressive stretch (SPS) devices use a ratchet, crank, or turnbuckle that the patient turns to incrementally increase end-range stretch within each session

Intensity and session durationProvide low- to moderate- (or moderate- to high-) intensity stretch; typically used 15–30 minutes per session, often multiple sessions per day

Typical body sitesSPS devices are available for knee, shoulder, ankle, wrist, and for pronation/supination

Patient action during usePatients adjust the device to the maximum tolerated end-range position, hold for several minutes to allow tissue relaxation, then advance to a new position

Serial stretch (serial/serial stretch) devices — description

Device mechanism

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

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

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 10, 2015

Next Review Date

Key ActionVerify member benefits and coverage determinations; prior authorization is not applicable but devices listed are not covered or are not medically necessary per this policy.

SourceLink

On This Page

Denial Risk

Coverage Denial Risk

BlueCHiP for Medicare: Patient‑controlled end range of motion stretching devices are not covered as the evidence is insufficient to determine the effects of the technology on health outcomes. Commercial Products: Patient‑controlled end range of motion stretching devices are considered not medically necessary for commercial members as the evidence is insufficient to determine the effects on health outcomes. Claims for Medicare Advantage (BlueCHiP for Medicare) will be denied as not covered; commercial claims may be denied as not medically necessary.

BlueCHiP for Medicare — Not covered (claims denied)
Commercial — Considered not medically necessary (claims may be denied)

Note

Conservative Care Context

Conservative care: Treatment of arthrofibrosis typically begins with postoperative physical therapy, pressure stretching techniques, and home exercises. If rehabilitation fails, options may include serial casting, static braces, or dynamic splints that provide low‑load prolonged stretch. Dynamic splints use spring loading or elastic bands to provide low‑intensity tension and are designed for extended wear (for example, 6–8 hours or overnight). Patient‑controlled end range of motion stretching devices are considered only after appropriate conservative measures have been tried and documented; however, these devices remain not covered or not medically necessary per plan.

Document prior conservative treatments (physical therapy, home exercise, pressure stretching) before device consideration
Document failure of conservative measures when applicable

Serial stretch devices (e.g., ERMI) use a hydraulic pump to alternate periods of higher-intensity stretch and relaxation, amplifying applied force to produce joint torque similar to therapist-applied torque

Operation and controlThe patient controls load via a hydraulic lever or pump; the hydraulic system amplifies lever force into greater torque applied to the joint

Typical cycle patternPeriods of stretch (about 5–10 minutes) are interspersed with recovery intervals of 5–10 minutes where the joint is released toward neutral

Device examplesERMI line devices include Shoulder Flexionater, Knee Flexionater/Extensionater, Elbow Extensionater, and MPJ Extensionater