RetiredCareSourcePolicy AR-PASSE-MM1380_

Mechanical Stretching Devices AR-PASSE-MM1380_

Defines medical necessity criteria, covered indications, and non-covered/experimental indications for mechanical stretching (dynamic splinting) devices (LLPS, SPS, PASS) as durable medical equipment (DME) for Arkansas PASSE members. Includes coverage periods, re-evaluation timing, and lists indications considered experimental/investigational.

Policy Summary

PayerCareSource

PolicyMechanical Stretching Devices AR-PASSE-MM1380_

Policy CodePolicy AR-PASSE-MM1380_

Change TypeArchived

Effective DateSep 1, 2023

Next Review Date

Key ActionProviders must document signs and symptoms of persistent joint stiffness/contracture, prior 3 weeks of exercise/skilled therapy, and physician judgment that limited ROM poses a meaningful functional limitation.

SourceLink

POLICY UPDATE CHANGES

Policy archived and no longer active as of 08/31/2024.

Added examples of PASS and SPS devices during annual review.

1Joints explicitly covered

14Indications experimental/investigational

4 monthsMax treatment duration (conditional)

Coverage Summary

This policy covers mechanical stretching (dynamic splinting) devices — including LLPS, SPS, and PASS — as durable medical equipment for Arkansas PASSE members, defining medical necessity criteria, covered indications, and non-covered/experimental indications. Status: RETIRED (Date Archived: 08/31/2024), Effective Date: 09/01/2023. Coverage stance is mixed: the policy specifies a narrow covered indication (knee) when all clinical criteria are met, and lists multiple other indications and device types as experimental/investigational.

Medically Necessary Criteria

Medically Necessary - Dynamic Splinting Devices (LLPS) as adjunct DME

Covered when ALL of the following are met:

ALL of the following

Device is a dynamic splinting device (e.g., low-load prolonged duration stretch [LLPS])
CareSource considers dynamic splinting devices medically necessary DME as adjunct to physical therapy, massage and/or exercise for an existing joint contracture.
Applied for an existing joint contracture affecting the knee
Policy states medically necessary only for the following joint: knee.
Signs and symptoms of persistent joint stiffness or contracture
Clinical judgment required to document persistent stiffness/contracture.
Member has undergone three weeks of exercise and skilled therapy in the initial subacute injury or post-operative period3 weeks
Therapy must be in the initial subacute or post-operative period.
Limited range of motion that poses a meaningful functional limitation as judged by a physician
Device to be used for an initial period of four weeks4 weeks
Initial 4-week trial required.
If improvement noted after initial 4 weeks, may be used for another 4-week period with reevaluation, and then up to 4 months based on continued improvementinitial 4 weeks; +4 week extension; up to 4 months total
Maximum duration described up to 4 months with periodic reevaluation.

Medically Necessary - LLPS in acute post-operative period for additional ROM surgery

Covered when ALL of the following are met:

ALL of the following

Member is in the acute post-operative period following additional surgery to improve ROM of a previously affected joint
CareSource considers use of an LLPS device medically necessary in this scenario.
Use limited to LLPS devices
Initial treatment limited to an initial four-week period; can extend another four-week period if improvement noted, up to 4 monthsinitial 4 weeks; +4 week extension; up to 4 months total

Not Medically Necessary / Experimental and Investigational

CareSource considers dynamic splinting experimental and investigational for the following indications and device types:

ANY of the following

Adhesive capsulitis (frozen shoulder)
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 treatment of limb spasticity
Injuries of the ankle and shoulder
Multiple sclerosis
Muscular dystrophy
Plantar fasciitis
Rheumatoid arthritis
Stroke
Trismus
Patient actuated serial stretch (PASS) devices (example: ERMI Knee Extensionater®, ERMI Shoulder Extensionater®)
Static progressive stretch (SPS) devices (examples: Joint Active Systems (JAS) splints: JAS Elbow, JAS Shoulder, JAS Ankle, JAS Knee, JAS Wrist, JAS Pronation-Supination)

Provider Actions & Billing

Documentation Required

Document persistent joint stiffness/contracture and functional limitation

Document that the member has persistent joint stiffness or contracture and that the limited range of motion poses a meaningful functional limitation per physician judgment; include evidence of prior exercise and skilled therapy for three weeks.

Signs and symptoms of persistent joint stiffness/contracture
Documentation of three weeks of exercise and skilled therapy in the initial subacute or post‑operative period
Physician statement that limited ROM poses a meaningful functional limitation

Prior Authorization

Coverage requires demonstration of prior therapy and trial

Coverage is conditioned on completion of a three‑week course of exercise and skilled therapy in the initial subacute or post‑operative period and an initial four‑week device trial; if improvement is noted after four weeks the device may be used for another four‑week period and then up to four months with reevaluation; claims are subject to post‑payment review.

Claims for LLPS are subject to post‑payment review
Initial skilled therapy requirement: 3 weeks of exercise and skilled therapy
Initial device trial: 4 weeks, with possible additional 4‑week extension and up to 4 months total based on improvement

Billing Rule

Claims subject to post-payment review

All claims for LLPS devices are subject to post‑payment review under the policy.

Potential denial triggers include lack of documented three weeks of exercise/skilled therapy
No documented initial four‑week device trial or lack of documented reevaluation for extensions

Background & Evidence

Mechanical stretching devices (also called dynamic splinting systems) provide passive stretching to restore range of motion for joint stiffness or contracture and are used as adjuncts to physical therapy and exercise. They can apply stretching for longer durations than a therapist can and are used for extension or flexion of shoulder, elbow, wrist, fingers, knee, ankle, and toes.

Device types described in the policy include Low-Load Prolonged Duration Stretch (LLPS) devices (elastic traction maintaining tension via rubber bands or springs), Static Progressive Stretch (SPS) devices (hold joint in set position with manual angle adjustment, inelastic traction), and Patient Actuated Serial Stretch (PASS) devices (hold joint in position with manual angle modification and no inherent stress unless set at maximum ROM).

Evidence cited in the policy includes systematic reviews, randomized controlled trials, the Cochrane review, the Hayes, Inc. medical technology directory, and the MCG guideline A0882; these sources are referenced in support or background for the policy.

Definitions

Policy status / Retirement note