CurrentCapital BluecrossPolicy MP 6.039

Mechanical Stretching Devices for Contracture and Joint Stiffness

Medically necessary and investigational coverage guidance for dynamic splints, continuous passive motion (CPM) devices, and specific mechanical stretching devices used to treat joint stiffness, contracture, or diminished range of motion. Affects providers and members under Capital Blue Cross programs to which this policy applies.

Policy Summary

PayerCapital Bluecross

PolicyMechanical Stretching Devices for Contracture and Joint Stiffness

Policy CodePolicy MP 6.039

Change TypeCoding and investigational designation updates

Effective Date4/1/2025

Next Review DateN/A

Key ActionObtain medical director review for continued dynamic splinting use beyond 8 weeks.

SourceLink

POLICY UPDATE CHANGES

Added codes E1803-4, E1807-8, E1813-14, E1822-23, E1826-29 effective 01/01/2025.

Added code E1832 as investigational, effective 04/01/2025.

Changed dynamic splinting of the toe to medically necessary and moved E1830 from not medically necessary table to medically necessary table.

Background, rationale and references updated during consensus reviews.

8 weeksdynamic splinting continued use requires medical director review after

6 weeksCPM continued use beyond this after surgery generally not medically necessary

2 days

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

CPM should commence within this time of surgery

≥3 weeksdynamic splinting considered as adjunct to PT in sub-acute period

multipleHCPCS E-codes listed across covered and not covered sections

Coverage Criteria for Mechanical Stretching Devices

Dynamic Splinting Devices

Dynamic Splinting Devices — Covered when ANY of the following are met:

ANY of the following

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).
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.

Continuous Passive Motion (CPM) Devices

Continuous Passive Motion (CPM) Devices — CPM in the home setting may be considered medically necessary when ONE of the following is met:

ANY of the following

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).
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 (for example patients with complex regional pain syndrome, extensive arthrofibrosis or tendon fibrosis, or physical, mental, or behavioral inability to participate in active physical therapy).

Coverage by device category

Coverage by device category — Coverage stance by device type and HCPCS code:

ALL of the following

Covered when medically necessary: Dynamic splinting devices with HCPCS codes including, but not limited to, E1800, E1803, E1804, E1805, E1807, E1808, E1810, E1812, E1813, E1814, E1813 (and associated codes E1825-E1830) and related codes as listed in policy.
Not medically necessary; therefore not covered: Continuous passive motion device HCPCS E0936.
Not medically necessary; therefore not covered: Dynamic splinting devices listed as not medically necessary per policy (examples include codes such as E1802, E1815, E1822, E1823, E1840).
Investigational; therefore not covered: Joint Active System splints (static progressive stretch) and related HCPCS codes (examples include E1801, E1806, E1811, E1816, E1818, E1821, E1831, E1832, E1841 and others as specified in policy). Note: E1832 was added as investigational effective 04/01/2025.

Coverage criteria — exclusions and investigational devices

Coverage criteria — additional guidance and exclusions:

ALL of the following

Prophylactic use of dynamic splinting is considered not medically necessary for management of chronic contractures or for prevention of stiffness in conditions without documented, treatable sub-acute/post-operative stiffness.
CPM use for joints other than the knee (e.g., major hip or shoulder surgery) is considered not medically necessary.
Extensionator and flexionator devices (e.g., ERMI Extensionator/Flexionator products) are considered investigational due to insufficient evidence to support general conclusions concerning health outcomes.

Coding and Billing — HCPCS, ICD-10, Procedure Codes

Investigational HCPCS Codes - Joint active system splints (static progressive stretch)HCPCSNot Covered

E1801	joint active system splints (static progressive stretch)
E1806
E1811
E1816
E1818
E1821
E1831
E1832
E1841

Dynamic splinting / Other device HCPCS - Mixed coverageHCPCS

E1802	dynamic splinting devices
E1815
E1822
E1823
E1840
E1800
E1803
E1804
E1805
E1807

1–10 of 21

1/3

Continuous passive motion (CPM) HCPCS - Mixed coverageHCPCS

E0936	continuous passive motion device (CPM) - not medically necessary therefore not covered
E0935	continuous passive motion device (CPM) - covered when medically necessary

ICD-10-CM Diagnosis Codes referencedICD-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, not elsewhere classified
M25.622	Stiffness of left elbow, not elsewhere classified
M25.631	Stiffness of right wrist, not elsewhere classified
M25.632	Stiffness of left wrist, not elsewhere classified

1–10 of 20

1/2

Procedure Codes listedCPT

29126
29131

HCPCS codes added/modified in policy historyHCPCS

E1803
E1804
E1807
E1808
E1813
E1814
E1822
E1823
E1826
E1827

1–10 of 14

1/2

ICD-10 codes referenced in policy historyICD-10

M25.69

other joint pain (ICD-10 code added to policy history)

Provider Actions, Documentation, and Authorization

Prior Authorization

Coverage and Plan Verification Required

Coverage must be verified with the member's benefit plan prior to claim submission. Identification of codes in the coding section does not guarantee coverage or separate reimbursement eligibility; confirm benefits, any applicable limitations, and whether prior authorization is required.

Code identification does not denote coverage — check member benefit plan.
Some covered services may not be eligible for separate reimbursement.

Prior Authorization

Prior Authorization — Verify with Payer

Prior authorization requirements are not explicitly stated in this policy. Providers should verify prior authorization requirements with the member's plan or payer-specific administration before device rental or purchase.

Policy does not specify a PA process — contact payer for plan-level rules.
Check member benefits for any PA, medical necessity review, or rental-term limits.

Background and Scope

Joint stiffness and contracture arise after surgery, trauma, immobilization, or neurologic conditions. Mechanical devices provide two principal therapeutic approaches: continuous passive motion (CPM), which passively moves a joint through a controlled range of motion, and dynamic or static progressive splinting, which apply prolonged low‑load stretch to increase range of motion or prevent adhesions.

Evidence and policy support for CPM are strongest for knee procedures (e.g., articular cartilage repair, certain complex post‑TKA situations) with specific timing recommendations (start within 2 days, maximum benefit within 14 days, and limited benefit beyond 6 weeks). Evidence for CPM in other joints and for some mechanical devices (for example, Extensionator/Flexionator and joint active system splints) is limited, which is reflected in investigational designations or not‑medically‑necessary classifications in the policy.

Definitions and Terminology

PASSIVE MOTION

Typical performersDelivered by a physical therapist or automated equipment such as a continuous passive motion (CPM) device.

PurposeTo maintain or increase joint range of motion and prevent stiffness or adhesions when active motion by the patient is not possible or is limited.

IMMEDIATE POSTOPERATIVE PERIOD

Timing definitionImmediate postoperative period: the time within one week of the surgical procedure; may be extended up to 30 days after surgery given individual circumstances.

Use implicationsGuides interpretation of early postoperative device use (e.g., CPM initiation and coverage considerations).

FlexibilityExtension beyond one week (up to 30 days) allowed based on individual clinical circumstances documented in the record.

Policy Revision History and Administrative Changes

2024-12-11administrative_update

Added HCPCS codes E1803, E1804, E1807, E1808, E1813, E1814, E1822, E1823, E1826, E1827, E1828, and E1829 to the policy (effective 01/01/2025).

2025-03-13administrative_updateLatest

Designated HCPCS code E1832 as investigational (INV), effective 04/01/2025.

2022-06-09minor_review

Policy Summary

PayerCapital Bluecross

PolicyMechanical Stretching Devices for Contracture and Joint Stiffness

Policy CodePolicy MP 6.039

Change TypeCoding and investigational designation updates

Effective Date4/1/2025

Next Review DateN/A

Key ActionObtain medical director review for continued dynamic splinting use beyond 8 weeks.

SourceLink

On This Page

Denial Risk

Denial Risk for Extended CPM Use

Continued use of CPM beyond six (6) weeks following any surgery is generally considered not medically necessary and may be denied. Providers should document clinical rationale and attempts at alternative rehabilitation when requesting extended use.

Continued CPM > 6 weeks post-surgery is generally not medically necessary.
Document start date (should commence within 2 days of surgery), clinical response, and justification for extension.

Billing Rule

CPM Coverage Distinction by Code

CPM coverage is limited and varies by code and clinical indication. E0936 is listed as not medically necessary in the policy's coding section, while other CPM-related codes may be considered covered when medically necessary. Verify the applicable HCPCS code and medical necessity determination for each request.

E0936 — listed as not medically necessary (not covered) in policy coding.
Other CPM codes may be covered when medically necessary — confirm specific code status and indication.

Note

Reference to Potential Coverage Limits (DME NCD)

This policy references Medicare/Medicaid DME coverage rules (NCD 280.1) which may affect coverage determinations for durable medical equipment. Providers should consider program-specific coverage limits and payer DME policies when submitting requests.

NCD 280.1 may impose additional limits or exclusions for DME items.
Plan-level or program-specific DME rules can supersede general policy language; verify applicability.

Documentation Required

Adjunct to Physical Therapy — Documentation Expected

CPM and dynamic splinting are intended as adjuncts to physical therapy in specified clinical scenarios. Requests should include documentation of PT participation, therapy goals, clinical signs of stiffness or limited motion, timing relative to injury/surgery, and response to conservative measures.

Dynamic splinting: used as an adjunct to PT in sub-acute/post-operative period (≥3 weeks post-injury/surgery) or acute post-op when prior history of motion loss exists.
CPM: used as an adjunct to PT for specified knee/cartilage procedures or when patient cannot participate in active PT.
Include PT documentation and trial of conservative therapy in the medical record.

Static progressive stretch / joint active system splints

Device descriptionStatic progressive stretch (joint active system) splints: devices that apply a controllable, incremental stretch to increase joint range of motion.

Coverage stanceDesignated investigational and therefore not covered (examples: HCPCS E1801 and related procedure codes listed).

HCPCS examplesPolicy lists E1801 and multiple related procedure codes (E1806, E1811, E1816, E1818, E1821, E1831, E1832, E1841) as investigational, not covered.

Dynamic splinting devices

Device descriptionDynamic splinting devices: devices that provide a dynamic stretching force to increase joint mobility.

Coverage stanceListed as not medically necessary and therefore not covered (policy identifies multiple HCPCS examples under the dynamic splinting NMN list).

Examples referencedPolicy cites HCPCS group for dynamic splinting (e.g., E1802 and associated procedure codes) as not medically necessary.

Continuous passive motion (CPM) device

DefinitionContinuous passive motion (CPM) device: a device that passively moves a joint through a controlled range of motion without patient effort.

Coding distinctionPolicy distinguishes CPM HCPCS codes by coverage status (example: E0935 = CPM covered when medically necessary; E0936 = CPM not medically necessary and not covered).

Typical indication contextPrimarily discussed for knee applications (e.g., post-articular cartilage repair, TKA rehabilitation) with device-specific coverage rules.

CPM

Short definitionCPM: continuous passive motion — a device or therapy that moves a joint continuously through a controlled ROM without patient effort.

Primary evidence focusEvidence and guidance in the policy focus mainly on CPM use after knee procedures and TKA, per referenced studies and reviews.

Clinical roleConsidered an adjunct to physical therapy in selected postoperative scenarios per policy criteria.

Dynamic splinting

Short definitionDynamic splinting: mechanical devices that apply a sustained or variable stretching force to increase joint mobility and treat contracture.

Coding/history notePolicy history documents coding changes (e.g., E1830 moved from NMN to MN) and administrative updates adding multiple HCPCS codes effective 01/01/2025.

Coverage contextSome dynamic splinting codes are listed as not medically necessary, while others have mixed or covered-when-medically-necessary status per the HCPCS groupings.

Changed dynamic splinting of the toe to medically necessary and updated coding, moving E1830 from not medically necessary to medically necessary.

2023-07-20administrative_update

Moved HCPCS code E1830 from the not medically necessary table to the medically necessary table (coding update).

2020-09-01administrative_update

Added ICD-10 code M25.69 to the policy.