CurrentCareSource GeorgiaPolicy N/A

Mechanical Stretching Devices (Dynamic Splinting) — Coverage Criteria

Customize your policy alerts

Sign up for all CareSource Georgia policy alerts

Know when CareSource Georgia releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Coverage rules for mechanical stretching (dynamic splinting) devices as durable medical equipment (DME) for members of CareSource Marketplace plans in specified states, including medical necessity criteria, non-covered indications, and device-type determinations.

Policy Summary

PayerCareSource Georgia

PolicyMechanical Stretching Devices (Dynamic Splinting) — Coverage Criteria

Policy CodePolicy N/A

Change TypeMaterial operational updates (added documentation and device examples)

Effective DateJun 1, 2026

Last ReviewMay 22, 2024

Next Review DateN/A

Key ActionDocument a ≥3-week trial of supervised PT/exercise and provide objective ROM and functional improvement plus evidence of device wear/compliance before coverage is approved.

SourceLink

POLICY UPDATE CHANGES

Added compliance documentation requirements to Section I.C. and ROM and improvement documentation to I.E.

E-voted addition of ankle and toe to policy to match fee schedule and MCG.

Added examples of PASS and SPS devices to the policy.

6joints listed as medically necessary (knee, elbow, wrist, finger, ankle, toe)

3+ weeksrequired prior PT/exercise trial duration

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentCareSource GeorgiaPolicy N/A

Mechanical Stretching Devices (Dynamic Splinting) — Coverage Criteria

Customize your policy alerts

Sign up for all CareSource Georgia policy alerts

Know when CareSource Georgia releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerCareSource Georgia

PolicyMechanical Stretching Devices (Dynamic Splinting) — Coverage Criteria

Policy CodePolicy N/A

Change TypeMaterial operational updates (added documentation and device examples)

Effective DateJun 1, 2026

Last ReviewMay 22, 2024

Next Review DateN/A

Key ActionDocument a ≥3-week trial of supervised PT/exercise and provide objective ROM and functional improvement plus evidence of device wear/compliance before coverage is approved.

SourceLink

POLICY UPDATE CHANGES

Added compliance documentation requirements to Section I.C. and ROM and improvement documentation to I.E.

E-voted addition of ankle and toe to policy to match fee schedule and MCG.

Added examples of PASS and SPS devices to the policy.

6joints listed as medically necessary (knee, elbow, wrist, finger, ankle, toe)

3+ weeksrequired prior PT/exercise trial duration

Coverage Criteria

Initial coverage criteria

Covered when ALL of the following are met:

Primary criteria: Device is used as an adjunct to physical therapy, massage, and/or exercise for an existing joint contracture.

Joint: Affected joint is one of: knee, elbow, wrist, finger, ankle, or toe.

Therapy trial: Member has completed at least 3 weeks of exercise, physical therapy, and skilled therapy in the initial subacute injury or post-operative period.>= 3 weeks

Clinical findings: Persistent joint stiffness or contracture is present.

Functional limitation: Limited range of motion poses a meaningful functional limitation as judged by a physician.

Compliance documentation: Documentation demonstrates compliance with device wear and with any additional activity and exercise recommended by the medical professional.

Outcome documentation: Documentation shows objective range-of-motion (ROM) measurements and functional improvement when applicable.

Duration / continuation

Use and continuation timing rules:

General duration: Device may be used for an initial period of 4 weeks, may be continued for a subsequent 4-week period after reevaluation, and may be used up to 4 months based on continued improvement.initial 4 weeks; additional 4 weeks with reevaluation; up to 4 months

Acute post-operative LLPS: For members who have undergone additional surgery to improve range of motion of a previously affected joint, LLPS is medically necessary for an initial 4-week period and an additional 4-week period if improvement was noted after the initial 4 weeks, for up to 4 months total.initial 4 weeks then additional 4 weeks if improved; up to 4 months

CareSource considers dynamic splinting experimental and investigational (non‑covered) for the following indications (including but not limited to): adhesive capsulitis, carpal tunnel syndrome, cerebral palsy, foot drop associated with neuromuscular diseases, hallux valgus, head and spinal cord injuries, improvement of outcomes following botulinum toxin injection for limb spasticity, injuries of the ankle and shoulder, multiple sclerosis, muscular dystrophy, plantar fasciitis, rheumatoid arthritis, stroke, and trismus.

Patient Actuated Serial Stretch (PASS) devices hold a joint in a set position but allow the patient to manually modify joint angle; CareSource cites specific examples and considers these devices experimental due to insufficient evidence (examples: ERMI Knee Extensionater® and ERMI Shoulder Extensionater®).

Static Progressive Stretch (SPS) devices hold a joint in a set position with manual angle modification; specific examples named as investigational include Joint Active Systems (JAS) splints such as JAS Elbow, JAS Shoulder, JAS Ankle, JAS Knee, JAS Wrist, and JAS Pronation‑Supination.

Accordingly, use of dynamic splinting devices for the indications listed above is considered experimental and investigational (not covered) by CareSource.

Provider Actions and Requirements

Prior Authorization

Medical necessity prerequisites for DME LLPS/SPS/PASS

CareSource considers dynamic splinting devices medically necessary DME only when used as an adjunct to physical therapy, massage, and/or exercise for an existing joint contracture and all clinical criteria in Section I are met, including joint limited to knee, elbow, wrist, finger, ankle, or toe, persistent joint stiffness/contracture, meaningful functional limitation per a physician, and required documentation of compliance and objective improvement.

Device must be adjunct to PT/massage/exercise for an existing joint contracture
Covered joints: knee, elbow, wrist, finger, ankle, toe
All clinical criteria in Section I must be met

Step Therapy

Require ≥3 weeks of therapy before device consideration

The member must have completed at least 3 weeks of exercise, physical therapy, and skilled therapy in the initial subacute injury or post‑operative period before device coverage is considered.

Device Type Definitions

LLPS — definition of Low-load Prolonged Duration Stretch Devices

TermLow-load Prolonged Duration Stretch (LLPS) devices

DefinitionDevices that permit resisted active and passive motion (elastic traction) within a limited range

MechanismMaintain a set level of tension using incorporated rubber bands or springs (elastic traction)

Clinical roleUsed as adjunct DME to physical therapy, massage, and/or exercise for existing joint contracture when criteria met

PASS — Patient Actuated Serial Stretch device definition

TermPatient Actuated Serial Stretch (PASS) devices

Medical Necessity Determination

DME medical necessity

DME considered medically necessary when ALL of the following criteria are met:

DME medical necessity: Device is prescribed as durable medical equipment to be used as an adjunct to physical therapy, massage, and/or exercise for an existing joint contracture; the affected joint is knee, elbow, wrist, finger, ankle, or toe; member has completed at least 3 weeks of exercise, PT and skilled therapy in the initial subacute injury or post-operative period; persistent joint stiffness or contracture exists; limited ROM causes a meaningful functional limitation per physician judgment; documentation demonstrates compliance with wear and recommended activity/exercise; and documentation shows objective ROM measurements and functional improvement when applicable.

Rental and Purchase Rules

Equipment	Rental vs Purchase	Policy details
Low-load prolonged duration stretch devices (LLPS)	Not specified	May be used for an initial period of 4 weeks; an additional 4-week period is permitted if improvement is noted after the initial 4 weeks; total use may continue for up to 4 months based on continued improvement. All claims for LLPS are subject to post-payment review by CareSource.

Required Documentation

Documentation Required

Require objective ROM, functional improvement, and compliance evidence

Clinical records must include objective range‑of‑motion measurements and evidence of functional improvement, plus documentation of compliance with device use and prescribed therapy/exercise.

Objective ROM measurements demonstrating baseline and follow‑up values (Section I.E)
Evidence of functional improvement after device use (Section I.E)
Documentation of adherence to wear and prescribed activity/exercise (Section I.C)

Background

Mechanical stretching devices (also termed dynamic splinting) provide sustained passive stretch to restore or improve joint range of motion (ROM) and address joint stiffness or contracture. These devices are intended to be used as an adjunct to physical therapy, exercise, and other skilled therapy to maintain prolonged stretch that cannot be sustained during routine therapy sessions.

Not Covered / Experimental

PASS and SPS devices (examples named above) are listed as not covered because CareSource considers the current scientific evidence insufficient to demonstrate clinical efficacy. The policy explicitly lists the same clinical indications noted as investigational—such as adhesive capsulitis, stroke, multiple sclerosis, muscular dystrophy, plantar fasciitis, rheumatoid arthritis, trismus, carpal tunnel syndrome, cerebral palsy, foot drop, hallux valgus, head and spinal cord injuries, improvement of outcomes after botulinum toxin injection, and injuries of the ankle and shoulder—for which use of these devices is considered experimental and therefore not covered. All claims for LLPS are also subject to post‑payment review by CareSource.