CurrentCareSourcePolicy N/A

Mechanical Stretching Devices (Dynamic Splinting) — DME Coverage Criteria (AR PASSE)

Customize your policy alerts

Sign up for all CareSource policy alerts

Know when CareSource 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 governing coverage and clinical criteria for mechanical stretching devices (dynamic splinting systems) as durable medical equipment for members in the Arkansas PASSE program; defines when devices are medically necessary, non-covered, and documentation requirements.

Policy Summary

PayerCareSource

PolicyMechanical Stretching Devices (Dynamic Splinting) — DME Coverage Criteria (AR PASSE)

Policy CodePolicy N/A

Change TypeOperational — documentation requirement added

Effective DateJun 1, 2026

Last ReviewMar 11, 2026

Next Review DateN/A

Key ActionProvide documentation showing compliance with device wear, recommended activity/exercise, and objective ROM and functional improvement for continued coverage and reevaluation.

SourceLink

POLICY UPDATE CHANGES

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

knee-onlyjoint(s) for which devices are medically necessary

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.

CurrentCareSourcePolicy N/A

Mechanical Stretching Devices (Dynamic Splinting) — DME Coverage Criteria (AR PASSE)

Customize your policy alerts

Sign up for all CareSource policy alerts

Know when CareSource 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

PolicyMechanical Stretching Devices (Dynamic Splinting) — DME Coverage Criteria (AR PASSE)

Policy CodePolicy N/A

Change TypeOperational — documentation requirement added

Effective DateJun 1, 2026

Last ReviewMar 11, 2026

Next Review DateN/A

Key ActionProvide documentation showing compliance with device wear, recommended activity/exercise, and objective ROM and functional improvement for continued coverage and reevaluation.

SourceLink

POLICY UPDATE CHANGES

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

knee-onlyjoint(s) for which devices are medically necessary

Coverage Criteria

Initial coverage criteria

Covered when ALL of the following are met for existing joint contracture:

Knee joint limitation: Device is medically necessary only for the knee joint

policy I.A

Prior conservative therapy: At least three weeks of exercise, physical therapy and skilled therapy in the initial subacute injury or post-operative period3 weeks

policy I.B

Clinical signs: Signs and symptoms of persistent joint stiffness or contracture

policy I.B.1

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

policy I.B.2

Compliance documentation: Documentation showing compliance with wear and compliance with any additional activity and exercise recommended by a medical professional

policy I.C

Treatment duration and reevaluation: May be used for an initial period of 4 weeks and a subsequent 4-week period with reevaluation and then up to 4 months based on continued improvementinitial 4 weeks; extendable to up to 4 months

policy I.D

Objective improvement: Documentation to show objective range of motion (ROM) and functional improvement

policy I.E

Acute post-operative coverage (LLPS)

Covered for acute post-operative use after additional surgery to improve ROM when ALL criteria met:

Device type: Use of an LLPS (Low-Load Prolonged Duration Stretch) device

policy II

Initial duration: Initial 4-week period4 weeks

policy II.A

Extension based on improvement: An additional 4-week period if improvement was noted after the initial 4 weeks, with coverage up to 4 months totalup to 4 months total

policy II.B

CareSource considers the use of dynamic splinting experimental and investigational 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 treatment of limb spasticity, injuries of the ankle and shoulder, multiple sclerosis, muscular dystrophy, plantar fasciitis, rheumatoid arthritis, stroke, and trismus.

CareSource considers the following device categories experimental and investigational due to insufficient scientific evidence of efficacy: patient actuated serial stretch (PASS) devices (for example, ERMI Knee Extensionater® and ERMI Shoulder Extensionater®) and static progressive stretch (SPS) devices (for example, Joint Active Systems (JAS) splints including JAS Elbow, JAS Shoulder, JAS Ankle, JAS Knee, JAS Wrist, and JAS Pronation‑Supination).

Dynamic splinting for the indications listed above and the specified PASS and SPS devices is considered not medically necessary because the available evidence is insufficient to demonstrate efficacy.

Provider Actions and Authorization

Prior Authorization

Prior Authorization / Authorization Period

Prior authorization required for dynamic splinting/LLP devices when used as adjunctive treatment for knee joint contracture. Authorization is granted for an initial 4-week period. If clinical improvement is documented after the initial 4 weeks, a subsequent 4-week authorization may be approved. Continued authorization beyond the two 4-week periods (up to a total of 4 months) may be approved based on documented ongoing objective range-of-motion (ROM) and functional improvement and clinician reevaluation.

Initial authorization period: 4 weeks
Continuation authorization: additional 4 weeks if improvement documented
Maximum authorization: up to 4 months total with documented ongoing improvement

Step Therapy

Conservative Therapy Requirement

Prior to consideration for coverage, members must have completed at least three weeks of conservative therapy (exercise, physical therapy, and/or other skilled therapy) in the initial subacute injury or post‑operative period with persistent joint stiffness or contracture and limited ROM causing meaningful functional limitation. Dynamic splinting is considered medically necessary only as an adjunct to these conservative measures.

Medical Necessity Criteria

DME medical necessity criteria

Medical necessity criteria for DME dynamic splinting (LLPS) for knee contracture:

Joint: Device must be for the knee

I.A

Conservative therapy prior: At least three weeks of exercise, physical therapy and skilled therapy3 weeks

I.B

Clinical findings: Signs and symptoms of persistent joint stiffness or contracture and meaningful functional limitation as judged by a physician

I.B.1-2

Definitions

LLPS — Low-Load Prolonged Duration Stretch Devices definition

TermLow-Load Prolonged Duration Stretch (LLPS) devices

DefinitionDevices that permit resisted active and passive motion using elastic traction and maintain a set level of tension by means of incorporated rubber bands or springs.

Typical useProvide prolonged low-load stretching as an adjunct to physical therapy or exercise for joint stiffness or contracture.

MechanismElastic traction (rubber bands or springs) to maintain continuous tension within a limited range.

PASS — Patient Actuated Serial Stretch devices definition

TermPatient Actuated Serial Stretch (PASS) devices

Rental and Purchase Rules

Equipment	Coverage status	Rental / Purchase rules	Authorization period / Notes
Low-Load Prolonged Duration Stretch (LLPS) devices for knee	Covered when all medical necessity criteria are met (device is medically necessary only for the knee; after ≥3 weeks of exercise, PT and skilled therapy; signs of persistent stiffness/contracture; limited ROM causing meaningful functional limitation; documentation of compliance and objective ROM/functional improvement).	Policy does not specify rental vs purchase; coverage is tied to meeting clinical criteria and documentation requirements.	Initial authorization for an initial 4-week period; may be extended for another 4-week period if improvement noted, with coverage up to 4 months total based on continued improvement. Documentation must support compliance and objective improvement.

Replacement

all dynamic splinting devices — replacement rules/key facts

Replacement interval specifiedPolicy provides no replacement interval for dynamic splinting devices (no interval specified).

Claims reviewAll claims for LLPS are subject to post-payment review.

Documentation requirement for continued coverageContinued coverage requires documentation of compliance with wear and objective ROM and functional improvement (per documentation rules).

ApplicabilityApplies to all dynamic splinting device types (LLPS, PASS, SPS) unless otherwise stated in coverage/exclusion sections.

Documentation Requirements and Re-evaluation

Documentation Required

Documentation required for continued coverage and reevaluation

For continued coverage and at each reevaluation, providers must document member compliance with wear and prescribed activity/exercise and provide objective ROM measurements and evidence of functional improvement.

Include objective ROM measurements and physician-assessed functional improvement in follow-up notes.
Document adherence to recommended wear schedule and any adjunctive exercise/therapy.

Background

Mechanical stretching devices are designed to provide prolonged passive stretch to improve joint range of motion in patients with stiffness or contracture. They are used as adjuncts to physical therapy and exercise to maintain a stretch for longer periods than a therapist can provide. Device classes include low‑load prolonged duration stretch (LLPS), static progressive stretch (SPS), and patient actuated serial stretch (PASS), each differing in how they apply tension and permit active or passive motion.

Not Covered / Exclusions

The following indications and device examples are not covered: 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 treatment of limb spasticity; injuries of the ankle and shoulder; multiple sclerosis; muscular dystrophy; plantar fasciitis; rheumatoid arthritis; stroke; and trismus. Specific device examples considered not covered include PASS devices (e.g., ERMI Knee Extensionater®, ERMI Shoulder Extensionater®) and SPS devices (e.g., Joint Active Systems splints such as JAS Elbow, JAS Shoulder, JAS Ankle, JAS Knee, JAS Wrist, and JAS Pronation‑Supination).