CurrentCareSourcePolicy N/A

Mechanical Stretching Devices (Dynamic Splinting) — Arkansas PASSE

This policy governs coverage and medical necessity criteria for mechanical stretching devices (dynamic splinting systems) as durable medical equipment (DME) for members with joint stiffness or contracture in Arkansas PASSE population.

Policy Summary

PayerCareSource

PolicyMechanical Stretching Devices (Dynamic Splinting) — Arkansas PASSE

Policy CodePolicy N/A

Change TypeMinor / no material changes

Effective DateSep 1, 2024

Next Review DateN/A

Key ActionDocument at least three weeks of skilled therapy and a physician assessment showing limited range of motion before seeking authorization for a dynamic splinting device.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

kneeMedically necessary joint

4 wksInitial trial

up to 4 moMax duration

multipleExperimental indications

post-payment reviewClaims subject to

Coverage and Medical Necessity Criteria

Medical necessity for dynamic splinting devices

Covered when ALL of the following are met:

Primary coverage criteria: Member has an existing joint contracture and the device is being used as an adjunct to physical therapy, massage, and/or exercise; at least three weeks of exercise and skilled therapy in the initial subacute injury or post-operative period have been completed; physician documents a limited range of motion that poses a meaningful functional limitation; signs and symptoms of persistent joint stiffness or contracture are present.

Knee is explicitly listed as a medically necessary joint in this policy.

Treatment duration and reevaluation

Initial and continuation treatment timing:

Treatment duration and reevaluation: Initial use is for an initial 4-week period with reevaluation; if improvement is noted after the initial 4 weeks, an additional 4-week period may be authorized; continuation based on demonstrated improvement may extend up to a total of 4 months.

Policy Summary

PayerCareSource

PolicyMechanical Stretching Devices (Dynamic Splinting) — Arkansas PASSE

Policy CodePolicy N/A

Change TypeMinor / no material changes

Effective DateSep 1, 2024

Next Review DateN/A

Key ActionDocument at least three weeks of skilled therapy and a physician assessment showing limited range of motion before seeking authorization for a dynamic splinting device.

SourceLink

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DME Medical Necessity Requirements

DME medical necessity

DME is medically necessary when the following DME-specific criteria are met:

DME criteria: Device is durable medical equipment used as an adjunct to physical therapy, massage, and/or exercise; at least three weeks of skilled therapy have been attempted in the initial subacute injury or post‑operative period; physician documents a functional limitation from limited range of motion and signs/symptoms of persistent joint stiffness or contracture; device is trialed for an initial 4-week period with documented improvement required for continuation, with total duration allowed up to 4 months based on continued improvement.Initial 4-week trial; up to 4 months total

Knee specifically noted as a medically necessary joint; all LLPS claims are subject to post-payment review.

Provider Requirements and Billing Risk

Prior Authorization

Prior therapy and physician documentation required

CareSource requires dynamic splinting devices to be used as an adjunct to physical therapy and that prior therapy and physician documentation criteria be met before authorization is implied.

Device must be adjunct to physical therapy, massage, and/or exercise.
Prior skilled therapy and physician documentation of functional limitation and persistent stiffness/contracture are required.

Step Therapy

Step therapy: trial of therapy first

Device use is considered only after at least three weeks of exercise and skilled therapy in the initial subacute injury or post‑operative period.

Three weeks of exercise and skilled therapy must be completed prior to considering a dynamic splinting device.

Documentation Required

Prior therapy documentation required

Documentation must demonstrate evidence of three weeks of exercise and skilled therapy in the initial subacute injury or post‑operative period.

Records of skilled therapy visits and home exercise adherence for at least three weeks.
Therapist notes describing the type, frequency, and duration of therapy provided.

Documentation Required

Physician assessment documenting functional limitation

Physician assessment must document limited range of motion that poses a meaningful functional limitation and signs/symptoms of persistent joint stiffness or contracture.

Physician judgment that limited ROM causes functional limitation.
Documentation of persistent stiffness or contracture signs and symptoms.

Denial Risk

Experimental/investigational exclusions

Use of dynamic splinting devices for the listed experimental/investigational indications is considered experimental/investigational and may be denied.

Examples include adhesive capsulitis, cerebral palsy, carpal tunnel syndrome, stroke, multiple sclerosis, rheumatoid arthritis, trismus, plantar fasciitis, muscular dystrophy, foot drop related to neuromuscular disease, and injuries of the ankle and shoulder.
PASS and SPS device examples are listed as experimental/investigational.

Denial Risk

Post‑payment review and denial risk for LLPS claims

All claims for LLPS devices are subject to post‑payment review and may be denied on review.

Submit complete documentation; claims may be retrospectively reviewed and denied if criteria are not met.

Non-Covered Devices and Indications

Adhesive capsulitis is named specifically under Non-covered services and is therefore not covered for dynamic splinting or other mechanical stretching device interventions.

Devices intended for indications listed as experimental/investigational (see exclusions list) are considered not covered. Examples of listed indications include neurologic, rheumatologic, and other musculoskeletal conditions enumerated in the exclusions.

Patient Actuated Serial Stretch (PASS) devices are explicitly listed among devices considered experimental/investigational by CareSource; example devices called out include the ERMI Knee Extensionater and ERMI Shoulder Extensionater.

Static Progressive Stretch (SPS) devices are listed as experimental/investigational due to insufficient scientific evidence; example devices include Joint Active Systems (JAS) splints such as JAS Wrist and JAS Pronation-Supination.

Device Type Definitions

inv-13: LLPS definition — Low-Load Prolonged Duration Stretch Devices

DefinitionDevices that permit resisted active and passive motion (elastic traction) within a limited range, maintaining a set level of tension by means of incorporated rubber bands or springs.

Typical mechanicsProvide elastic traction (rubber bands or springs) to maintain continuous low-load stretch over prolonged durations.

Clinical roleUsed as adjuncts to physical therapy, massage, and/or exercise to address joint contracture and restore range of motion.

Covered indicationMedically necessary as DME for an existing joint contracture (knee explicitly listed) when clinical criteria are met.

Use constraintsMust follow at least three weeks of exercise and skilled therapy and be trialed initially for 4 weeks with reevaluation.

inv-14: SPS definition — Static Progressive Stretch Devices

DefinitionDevices that hold the joint in a set position but allow for manual modification of the joint angle and may allow active motion without resistance (inelastic traction).

Typical mechanicsProvide inelastic, static positioning with manual adjustment of angle to progressively increase range of motion.

Clinical roleUsed as part of dynamic splinting approaches to restore ROM as an adjunct to therapy for contracture management.

Regulatory/coverage noteListed among mechanical stretching device types; policy treats SPS within same DME framework but some SPS devices are noted elsewhere as investigational for certain indications.

Use constraintsInitial trial and reevaluation schedule: initial 4-week use with reassessment and possible continuation based on improvement up to 4 months.

inv-15: PASS definition — Patient Actuated Serial Stretch Devices

DefinitionDevices that hold the joint in a set position but allow manual modification of joint angle and may allow active motion without resistance; the device exerts stress only when the joint angle is set at the maximum ROM.

Typical mechanicsInelastic traction with patient-actuated adjustments to serially increase stretch at end-range positions.

Clinical roleIntended to incrementally increase joint ROM by patient-controlled adjustments, used adjunctively with therapy for contractures.

Coverage statusPASS devices are included in device types but are listed elsewhere among devices considered experimental/investigational for some indications.

Use constraintsFollow same initial trial: at least three weeks of prior skilled therapy, initial 4-week trial with reevaluation and continuation up to 4 months if improved.

Rental, Purchase, and Replacement

Durable medical equipment classification	Rental vs. purchase rule
Devices described in this policy (LLPS, SPS, PASS and related dynamic splinting systems) are classified as durable medical equipment (DME).	Policy text does not specify an explicit rental versus purchase rule for these devices.

inv-18: Replacement — replacement-related key facts

Replacement interval detailsNo specific replacement intervals or schedules are specified in the policy; archived policy notes lack replacement rules.

Equipment classificationDevices are described as durable medical equipment (DME); policy does not provide explicit rental vs purchase rules.

Documentation for replacementClinical documentation requirements (prior 3 weeks of skilled therapy, physician assessment of functional limitation, persistent stiffness) apply to coverage decisions and would support replacement requests.

Post-payment review riskAll LLPS claims are subject to post-payment review and may be denied on review; replacement claims would be subject to same review processes.

Archival notePolicy was archived as of 05/31/2025; absence of replacement intervals may reflect archived status rather than clinical intent.

OpenPayer