CurrentCapital BluecrossPolicy MP 6.039

MECHANICAL STRETCHING DEVICES FOR CONTRACTURE AND JOINT STIFFNESS

Defines medical necessity, investigational and not medically necessary positions for mechanical stretching devices (dynamic splinting, Joint Active System splints, Extensionator/Flexionator devices, and continuous passive motion devices) across Capital Blue Cross products; includes clinical indications, duration limits, and coding/ICD-10 lists. Benefit applicability may vary by product and member plan.

Policy Summary

PayerCapital Bluecross

PolicyMECHANICAL STRETCHING DEVICES FOR CONTRACTURE AND JOINT STIFFNESS

Policy CodePolicy MP 6.039

Change TypeAdministrative/consensus updates

Effective DateApr 1, 2025

Next Review Date

Key ActionContinued use of dynamic splinting devices beyond 8 weeks requires medical director review.

SourceLink

POLICY UPDATE CHANGES

09/10/2020 Consensus Review: Background, Rationale and References updated; ICD-10 codes added.

09/01/2020 Administrative Update: Added ICD-10 code M25.69.

3Coverage categories (covered / not covered / investigational)

6Key CPT/HCPCS groups listed

40+ICD-10 diagnosis codes referenced

Scope: This policy (MP 6.039) addresses medical necessity, investigational, and not medically necessary positions for mechanical stretching devices for contracture and joint stiffness, including dynamic splinting, Joint Active System splints, Extensionator/Flexionator devices, and continuous passive motion (CPM) devices across Capital Blue Cross products.

Coverage stance: Mixed — some devices/uses are covered when medically necessary, some are not medically necessary / not covered, and some (e.g., Joint Active System, Extensionator/Flexionator) are investigational.

Effective date: 2025-04-01; Last review: 2022-09-10. Policy number: MP 6.039.

Timing limits and review triggers (thresholds)

Sub-acute period (dynamic splinting)At least 3 weeks after injury or surgery

Chronic contracture definition (dynamic splinting not covered prophylactically)No significant change in motion for a four-month period

CPM initiation windowUse should commence within 2 days of surgery

CPM usual maximum benefit windowMaximum benefit usually obtained within 14 days from the start of therapy

CPM maximum covered durationContinued use beyond 6 weeks following surgery generally not medically necessary

Dynamic splinting continuation review thresholdContinued use beyond an 8-week period requires medical director review

Medical Necessity Criteria

Dynamic splinting devices - Medically necessary

Dynamic splinting devices for the knee, elbow, wrist, finger, or toe may be considered medically necessary when ANY of the following are met:

ANY of the following

Adjunct to PT / sub-acute: As an adjunct to physical therapy when there are documented signs and symptoms of significant motion stiffness or loss in the sub-acute injury or post-operative period (i.e., at least three weeks after injury or surgery)at least 3 weeks after injury or surgery
Acute post-op with prior history: During the acute post-operative period where there is prior documented history of motion stiffness or loss in a joint when additional surgery or procedures are done to improve motion to that joint
Documentation of prior history required for coverage

Continuation review: Continued use beyond an eight (8) week period requires medical director review> 8 weeks

Operational prior authorization/medical director review required for >8 weeks

Dynamic splinting devices - Not medically necessary

Dynamic splinting is considered not medically necessary for prophylactic or chronic uses when the following apply:

Not medically necessary - prophylactic/chronic: Prophylactic use in the management of chronic contractures (no significant change in motion for a four-month period) AND joint stiffness due to joint trauma, fractures, burns, head and spinal cord injuries, rheumatoid arthritis, multiple sclerosis, muscular dystrophy, or cerebral palsyno significant change in motion for a four-month period

Joint Active System splints

Coverage position:

Investigational - Joint Active System: Joint Active System splints are considered investigational because there is insufficient evidence to support a general conclusion concerning the health outcomes or benefits associated with these devices

Extensionator and Flexionator devices

Coverage position:

Investigational - Extensionator/Flexionator: Extensionator and flexionator devices are considered investigational due to insufficient evidence of benefit

Continuous passive motion (CPM) devices - Medically necessary (home use)

Use of CPM in the home setting may be considered medically necessary as an adjunct to physical therapy when ANY of the following are met:

Indications for home CPM

Articular cartilage repair: During the non-weight bearing rehabilitation period following articular cartilage repair procedures of the knee (e.g., microfracture, osteochondral grafting, autologous chondrocyte implantation, treatment of osteochondritis dissecans, repair of tibial plateau fractures)
Low mobility / inability to comply: Under conditions of low postoperative mobility or inability to comply with rehabilitation exercises following a total knee arthroplasty (TKA), TKA revision or other major knee surgery; includes patients with complex regional pain syndrome, extensive arthrofibrosis or tendon fibrosis, or physical, mental, or behavioral inability to participate in active physical therapy
Clinical input supports use in these conditions

Timing and duration: Use should commence within two (2) days of surgery; maximum benefit is usually obtained within fourteen (14) days from the start of therapy; continued use beyond 6 weeks following surgery of any type is generally considered not medically necessary or appropriate

Continuous passive motion (CPM) devices - Not medically necessary

The following uses are considered not medically necessary:

Not medically necessary - CPM: Use of a CPM device for other joints including, but not limited to, major hip joint and shoulder surgery OR use of CPM beyond 6 weeks following surgery of any type (including after knee arthroscopy with microfracture)continued use beyond 6 weeks

Coding

Investigational / Not covered - Joint Active System splints (static progressive stretch)HCPCSNot Covered

E1801	Static progressive stretch splint (Joint Active System) listed under E1801 group
E1806	Procedure code referenced in investigational list
E1811	Procedure code referenced in investigational list
E1816	Procedure code referenced in investigational list
E1818	Procedure code referenced in investigational list
E1821	Procedure code referenced in investigational list
E1831	Procedure code referenced in investigational list
E1832	Procedure code referenced in investigational list
E1841	Procedure code referenced in investigational list

Not medically necessary / Not covered - Dynamic splinting devices (per policy heading)HCPCSNot Covered

E1802	Dynamic splinting devices group
E1815	Procedure code referenced in not medically necessary dynamic splinting list
E1822	Procedure code referenced in not medically necessary dynamic splinting list
E1823	Procedure code referenced in not medically necessary dynamic splinting list
E1840	Procedure code referenced in not medically necessary dynamic splinting list

Covered when medically necessary - Dynamic splinting devicesHCPCSCovered

E1800	Dynamic splinting / prefabricated/custom devices group
E1803	Procedure code referenced in covered dynamic splinting list
E1804	Procedure code referenced in covered dynamic splinting list
E1805	Procedure code referenced in covered dynamic splinting list
E1807	Procedure code referenced in covered dynamic splinting list
E1808	Procedure code referenced in covered dynamic splinting list
E1810	Procedure code referenced in covered dynamic splinting list
E1812	Procedure code referenced in covered dynamic splinting list
E1813	Procedure code referenced multiple times in covered list
E1814	Procedure code referenced in covered dynamic splinting list

1–10 of 19

1/2

Not medically necessary / Not covered - Continuous passive motion device (CPM)HCPCSNot Covered

E0936

Continuous passive motion device - not covered list

Covered when medically necessary - Continuous passive motion device (CPM)HCPCSCovered

E0935

Continuous passive motion device - covered when medically necessary list

Relevant ICD-10 diagnosis codes listed in policyICD-10

M24.521	Contracture, right elbow
M24.522	Contracture, left elbow
M24.531	Contracture, right wrist
M24.532	Contracture, left wrist
M24.561	Contracture, right knee
M24.562	Contracture, left knee
M25.621	Stiffness of right elbow
M25.622	Stiffness of left elbow
M25.631	Stiffness of right wrist
M25.632	Stiffness of left wrist

1–10 of 88

1/9

Provider Actions

Prior Authorization

Medical director review for extended dynamic splinting

Continued use of dynamic splinting devices beyond eight (8) weeks requires medical director review.

Continued use beyond 8 weeks

Prior Authorization

Time-limited CPM authorization

Use of CPM should commence within two (2) days of surgery. Continued use beyond six (6) weeks following surgery is generally considered not medically necessary and would require justification and medical director review.

E0935
E0936

Documentation Required

Document prior history of motion stiffness for acute post-op CPM or dynamic splinting

For acute post-operative use when there is a prior history of motion stiffness or loss in the joint, documentation of that prior history is required to support coverage. This documentation requirement applies to CPM devices and dynamic splinting.

Background and Rationale

Mechanical stretching devices include prefabricated or custom-fabricated splints and devices applied across a stiff or contractured joint to provide incremental tension and increase range of motion following surgery, trauma, immobilization, illness, or congenital abnormalities.

Dynamic splints are custom-fit, spring-loaded devices that provide a low-load, prolonged stretch and are available for elbow, wrist, finger, shoulder, knee, ankle and toes; examples include Dynasplint and other brand systems.

Continuous passive motion (CPM) devices move a joint passively (e.g., flexion/extension of the knee) without patient effort and have been primarily studied in the knee, especially after total knee arthroplasty (TKA) and after cartilage repair procedures.

Specific device types discussed in the policy include Joint Active System splints (static progressive stretch), Extensionator and Flexionator devices (patient-controlled pneumatic/serial stretching), and home-use CPM units for knee rehabilitation.

Clinical context: CPM is intended to stimulate articular tissue healing, synovial circulation, reduce edema and prevent adhesions/contractures; dynamic splinting is used as an adjunct to physical therapy for sub-acute stiffness or in the acute post-operative period when prior history of stiffness exists.

AAOS guideline (2015/2022): Strong evidence supports that CPM after knee arthroplasty does not improve outcomes; clinical input (2022) supports judicious, limited use as described in this policy.

Evidence certainty for CPM after cartilage repair: Insufficient — systematic reviews report histologic differences favoring CPM in some studies, but clinical outcome data are inadequate to permit conclusions on efficacy.

Passive motion: A therapeutic exercise technique used to move patients' joints through range of motion without patient effort; accomplished by a therapist or with equipment such as a CPM device.

Immediate postoperative period: Time period within one week of the surgical procedure; this period may be extended up to 30 days given individual circumstances.

Autologous chondrocyte transplantation (ACT): Surgical treatment aimed at repairing damaged hyaline cartilage by transplanting regenerated hyaline-like cartilage to restore usable function.

OpenPayer

MECHANICAL STRETCHING DEVICES FOR CONTRACTURE AND JOINT STIFFNESS

Coverage Summary

Medical Necessity Criteria

Coding

Provider Actions

Background and Rationale

Medicare Determinations

Revision History