CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

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

This policy governs coverage and medical necessity determinations for patient-controlled home stretching devices (static progressive stretch and serial stretch devices) used to improve joint range of motion for members of Blue Cross Blue Shield - Rhode Island.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPatient-controlled End Range of Motion Stretching Devices (Static Progressive and Serial Stretch Devices) Coverage Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionVerify member benefits and eligibility with the payor before ordering devices.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2Device types

8+HCPCS not covered

InsufficientEvidence conclusion

Coverage and Medical Necessity Determinations

Not Medically Necessary

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The policy explicitly excludes a set of HCPCS-listed static progressive stretch (SPS) device codes. The following codes are not covered for Medicare Advantage and are considered not medically necessary for Commercial Products: E1801, E1811, E1806, E1816, E1831, E1818, and E1841. Each code describes a patient-controlled SPS device for a specific joint (elbow, knee, wrist, ankle, toe, forearm pronation/supination, and shoulder) and includes all components and accessories.

Billing and Coding

Not covered HCPCS codesHCPCSNot Covered

E1801	Static progressive stretch elbow device, extension and/or flexion, 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
E1806	Static progressive stretch wrist device, flexion and/or extension, 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
E1831	Static progressive stretch toe device, extension and/or flexion, 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
E1841	Static progressive stretch shoulder device, with or without range of motion adjustment; includes all components and accessories

Functional knee flexion

Functional knee flexion threshold110 degrees (functional ROM necessary for common activities of daily living)

Provider Requirements and Actions

Prior Authorization

Prior authorization is not required for these devices per this policy. However, benefits and prior authorization rules can vary by contract; providers should verify member-specific requirements with Blue Cross Blue Shield of Rhode Island before providing equipment or submitting claims.

Prior authorization: Not applicable per policy — verify with payer and member Benefit Booklet/EOC

Note

Conservative Treatment Context

Conservative treatments should be attempted before consideration of serial static braces or dynamic splints. Typical conservative care includes postoperative physical therapy, pressure/stretching techniques, supervised home exercise programs, and, when indicated, physical manipulation under anesthesia, arthroscopic or open lysis of adhesions, or revision surgery.

Conservative options: postoperative rehabilitation, physical therapy, home exercises, pressure stretching techniques
When rehab fails: serial static braces or dynamic splints (low-load prolonged stretch worn for extended periods, e.g., 6–8 hours or overnight) may be considered

Documentation Required

Benefit Verification

Verify member benefits and coverage details prior to ordering or providing devices. Coverage may vary by group/contract and the member's Benefit Booklet / Evidence of Coverage (EOC) or Subscriber Agreement governs benefit determinations.

Check member Benefit Booklet / Evidence of Coverage / Subscriber Agreement for applicable benefits and exclusions
Contact BCBSRI provider call center to confirm eligibility, coverage, and any prior authorization requirements for the specific member

Denial Risk

Denial Triggers and Affected Codes

Claims for patient-controlled end range of motion stretching devices may be denied as not covered or not medically necessary. Providers should ensure documentation supports medical necessity and that the service is consistent with the member's covered benefits.

Devices considered not covered / not medically necessary for Medicare Advantage and Commercial Products: E1801, E1806, E1811, E1816, E1818, E1831, E1841
Denial reasons: device considered investigational/insufficient evidence, not medically necessary, or not a covered benefit under the member's contract

Clinical Background

Loss of full joint range of motion commonly follows surgery and may result from arthrofibrosis or periarticular fibrosis; this can cause significant functional limitations in activities of daily living. Treatment options typically begin with conservative measures such as physical therapy, home exercise programs, and dynamic or serial static splinting. When conservative rehabilitation fails, interventions may include manipulation under anesthesia, arthroscopic or open lysis of adhesions, revision surgery, or consideration of home-use devices intended to increase range of motion. The clinical goal of any intervention is improvement in functional outcomes—such as restoring sufficient joint motion to perform common tasks—rather than isolated gains in passive range of motion.

Device Definitions

Static progressive stretch (SPS) devices

DefinitionStatic progressive stretch (SPS) devices provide low- to moderate-intensity force to hold a joint at its end range and progressively increase stretch within each session using a ratchet or crank.

Typical session duration15–30 minutes per session, multiple sessions per day (individuals typically instructed 30 minutes, 3 times per day).

Mechanics of useDuring each session the device is advanced to the maximum tolerated end-range position and held for several minutes to allow tissue relaxation before further advancement.

Serial stretch devices

DefinitionSerial stretch devices use a hydraulic pump to alternate higher-intensity stretch periods with relaxation intervals to achieve progressive gains in range of motion (example: ERMI line).

ExampleERMI devices (e.g., Shoulder Flexionater; Knee Flexionater; Knee Extensionater; Elbow Extensionater; MPJ Extensionater).

MechanismThey apply torque near therapist-applied levels for 5–10 minute stretch periods interspersed with 5–10 minute recovery intervals to allow tissue relaxation and progressive improvement.