ModifiedBlue Cross of IdahoPolicy MP 1.03.05

Patient-Controlled End Range of Motion Stretching Devices

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This policy governs coverage of patient-controlled static progressive and serial end range of motion stretching devices used in the home for impaired joint range of motion. These devices are considered investigational under the policy, subject to applicable member benefit terms and exceptions.

Policy Summary

PayerBlue Cross of Idaho

PolicyPatient-Controlled End Range of Motion Stretching Devices

Policy CodePolicy N/A

Change TypeNew policy

Effective DateJan 1, 202747d

Last ReviewSep 24, 2026

Next Review DateN/A

Key ActionReview requests for patient-controlled end range of motion stretching devices as investigational, including static progressive and serial devices.

SourceLink

POLICY UPDATE CHANGES

Blue Cross of Idaho newly adopted a policy stating that patient-controlled end range of motion stretching devices, including static progressive and serial devices, are investigational.

Investigational

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ModifiedBlue Cross of IdahoPolicy MP 1.03.05

Patient-Controlled End Range of Motion Stretching Devices

Customize your policy alerts

Sign up for Bluecross Idaho Policy MP 1.03.05 alerts

Get alerted when Policy MP 1.03.05 changes without checking for updates manually.

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Policy Summary

PayerBlue Cross of Idaho

PolicyPatient-Controlled End Range of Motion Stretching Devices

Policy CodePolicy N/A

Change TypeNew policy

Effective DateJan 1, 202747d

Last ReviewSep 24, 2026

Next Review DateN/A

Key ActionReview requests for patient-controlled end range of motion stretching devices as investigational, including static progressive and serial devices.

SourceLink

POLICY UPDATE CHANGES

Blue Cross of Idaho newly adopted a policy stating that patient-controlled end range of motion stretching devices, including static progressive and serial devices, are investigational.

Investigational

Coverage Criteria

Patient-controlled end range of motion stretching devices, including static progressive and serial devices, are considered investigational under this policy.

This policy applies to patient-controlled static progressive and serial end range of motion stretching devices used for home treatment of impaired joint range of motion. The listed HCPCS devices are designated investigational for all relevant diagnoses. The policy was newly added to the Durable Medical Equipment policy set and is effective January 1, 2027.

Coding and Clinical Reference Criteria

FDA Product CodeFDA

ION	FDA product code for Exerciser, Non-Measuring

Investigational for all relevant diagnosesHCPCSExperimental

E1399	Durable medical equipment, miscellaneous
E1801	Static progressive stretch/patient actualized serial stretch elbow device, extension
E1806	Static progressive stretch/patient actualized serial stretch elbow device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories
E1811	Static progressive stretch/patient actualized serial stretch knee device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories
E1816	Static progressive stretch/patient actualized serial stretch ankle device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories
E1821	Static progressive stretch/patient actualized serial stretch forearm pronation / supination device, with or without range of motion adjustment, includes all components and accessories
E1831	Replacement soft interface material/cuffs for bi-directional static progressive stretch device
E1832	Static progressive stretch toe device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories
E1841	Static progressive stretch/patient actualized serial stretch shoulder device, with or without range of motion adjustment, includes all components and accessories

Coding Thresholds

Functional knee range of motion110°

Coding Thresholds

Dynamic splint wear duration6 to 8 hours or overnight

Coding Thresholds

Abnormal knee extension deficit6° to 10° compared with the noninvolved knee

Coding Thresholds

Abnormal knee flexion deficit16° to 25° compared with the noninvolved knee

Coding Thresholds

Severely abnormal knee extension deficitMore than 10° compared with the noninvolved knee

Coding Thresholds

Severely abnormal knee flexion deficitMore than 25° compared with the noninvolved knee

Provider and Billing Actions

Denial Risk

Confirm investigational status before requesting coverage

Coverage may be denied because patient-controlled end range of motion stretching devices, including static progressive and serial devices, are considered investigational.

Denial Risk

Listed devices are investigational for all relevant diagnoses

Patient-controlled end range of motion stretching devices, including static progressive and serial devices represented by the listed codes, are considered investigational for all relevant diagnoses.

Applicable HCPCS codes include E1399, E1801, E1806, E1811, E1816, E1821, E1831, E1832, and E1841.

Clinical Background

Loss of joint range of motion may occur after surgery or injury and may be associated with arthrofibrosis, pain, and functional limitations. Arthrofibrosis involves a painful loss of end range of motion caused by periarticular fibrosis and bands of scar tissue. Treatment may include physical therapy, home exercises, manipulation, casting, static bracing, or dynamic splinting; this policy focuses on home-use mechanical devices that provide moderate- to high-intensity or static progressive stretching.

Definitions and Abbreviations

Definitions

ArthrofibrosisA painful loss of end range of motion compared with the normal contralateral side caused by periarticular fibrosis and bands of scar tissue.

Definitions

Static progressive stretch devicesDevices that provide low- to moderate-intensity stretching with a crank or ratchet that progressively increases the stretch within each session.

Definitions

Serial stretch devicesDevices that use hydraulics to alternate between periods of higher-intensity stretch and relaxation.

Definitions

Not Covered Services

The following are not covered because they are considered investigational: patient-controlled static progressive end range of motion stretching devices and patient-controlled serial end range of motion stretching devices. This designation applies to the listed devices and to all relevant diagnoses.