CurrentCentenePolicy CP MP.144

Mechanical Stretching Devices for Joint Stiffness and Contracture

Defines medical necessity criteria and coding guidance for mechanical stretching devices (primarily low-load prolonged-duration stretch/dynamic splinting) for knee, elbow, wrist, ankle, and finger joint stiffness/contracture, and describes devices not supported by evidence (SPS, PASS) and HCPCS codes that do/do not support coverage.

Policy Summary

PayerCentene

PolicyMechanical Stretching Devices for Joint Stiffness and Contracture

Policy CodePolicy CP MP.144

Change TypeCoding and criteria clarifications (HCPCS additions; ankle added; SPS/PASS not supported)

Effective Date

Next Review Date

Key ActionProvider must document the affected joint (knee, elbow, wrist, ankle, or finger), subacute timing or revision surgery scenario, functional limitation and prior therapy failure, and submit requests as a rental.

POLICY UPDATE CHANGES

Added new HCPCS codes E1803, E1804, E1807, E1808.

Added ankle to Criteria I and clarified that LLPS may be provided with or without adjunctive physical therapy; specified that criteria I.B is for a rental.

Removed SPS and PASS from medically necessary group and described them as not supported by current research.

Specified that LLPS/dynamic stretch devices are medically necessary for knee, elbow, wrist, ankle, and finger when criteria are met.

5Joints with covered LLPS indications

>=3w & <4mCovered post-op/subacute timeframe

Multiple

Coverage Summary

Defines medical necessity for low-load prolonged-duration stretch (LLPS) / dynamic stretch devices for persistent joint stiffness or contracture of the knee, elbow, wrist, ankle, and finger when specified criteria are met. The policy states that bi-directional static progressive stretch (SPS) devices and patient-actuated serial stretch (PASS) devices are not supported by current research. Covered LLPS requests must be for a rental and, in the subacute indication, the member must be >= 3 weeks and < 4 months post-injury or post-operation. Overall coverage stance is mixed, with LLPS/dynamic splinting supported for the listed joints and other device types or joints not listed described as not supported.

Quick facts & thresholds

Subacute period (covered timeframe)>= 3 weeks and < 4 months after injury or operation

Prior trial for revision surgeryInitial 4-week period + subsequent 4-week period with improvement on reevaluation after the second 4-week period

Joints covered (LLPS/dynamic stretch)Knee, elbow, wrist, ankle, finger (5 joints)

Devices NOT supported by current researchBi-directional static progressive stretch (SPS) devices and Patient‑actuated serial stretch (PASS) devices

HCPCS codes noted as not supporting coverage (examples)E1399, E1801, E1806, E1811, E1816, E1818, E1831, E1841

Coverage formatLLPS/dynamic stretch devices provided as rental when criteria met

Medical-Necessity Criteria

Medically Necessary (LLPS / dynamic stretch device)

LLPS/dynamic stretch device is medically necessary when ALL of the following are met:

ALL of the following

Functional response and therapy requirements
- Requested for one of the following joints: knee, elbow, wrist, ankle, or finger
- Member/enrollee is in the subacute injury or post-operative period (>= 3 weeks and < 4 months after injury or operation) with signs and symptoms of persistent joint stiffness or contracture>= 3 weeks and < 4 months
- Limited range of motion poses a meaningful functional limitation as judged by the physician

Not Supported or Experimental Uses

Not supported / Not recommended

Current research does not support the following:

ANY of the following

LLPS for any indication not noted in the medically necessary section (i.e., joints other than knee, elbow, wrist, ankle, or finger)
Bi-directional static progressive stretch (SPS) devices over other alternatives
Patient-actuated serial stretch (PASS) devices

Current peer-reviewed research and reviews show strongest support for LLPS/dynamic splinting at the knee, elbow, wrist, and fingers; the policy states that LLPS is not supported for indications outside those joints and that SPS and PASS devices lack supporting evidence. The policy notes that mechanical stretching devices are generally used as an adjunct to physical therapy and/or exercise when applicable.

Coding (HCPCS)

HCPCS codes that do NOT support coverage criteria (SPS or miscellaneous)HCPCSNot Covered

E1399	Durable medical equipment, miscellaneous.
E1801	Static progressive stretch elbow device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories.
E1806	Static progressive stretch wrist device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories.
E1811	Static progressive stretch knee device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories.
E1816	Static progressive stretch ankle device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories.
E1818	Static progressive stretch forearm pronation/supination device, with or without range of motion adjustment, includes all components and accessories.
E1831	Static progressive stretch toe device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories.
E1841	Static progressive stretch shoulder device, with or without range of motion adjustment, includes all components and accessories.

Provider-facing note: the policy specifies that covered LLPS devices are provided as a rental. Providers should bill using the applicable HCPCS rental codes for covered dynamic/LLPS devices (see supporting HCPCS list) and avoid billing with HCPCS codes designated as not supporting coverage (SPS/PASS/miscellaneous codes), as claims may be denied.

Provider Actions & Billing

Prior Authorization

Document medical necessity and joint/timeframe

Document the specific affected joint (knee, elbow, wrist, ankle, or finger), that the member is in the subacute period (>= 3 weeks and < 4 months post-injury or post-surgery) or meets the acute post-operative revision scenario, that limited range of motion causes a meaningful functional limitation as judged by the physician, and that the limitation has not responded to other therapy. Note the request is for a rental.

E1800
E1802
E1803
E1804
E1805
E1807
E1808
E1810
E1812
E1813
E1814
E1815
E1822
E1823

Background, Evidence, and Definitions

Background: Mechanical stretching devices encompass LLPS (dynamic splinting), SPS, and PASS devices and aim to prevent or treat joint contractures by restoring or maintaining range of motion. Evidence is strongest for LLPS/dynamic splinting at the knee, elbow, wrist, and fingers; evidence is insufficient to support LLPS at the shoulder or foot, and PASS devices have insufficient evidence. These devices are generally used as adjuncts to physical therapy and exercise.

Evidence: Multiple randomized trials and systematic reviews demonstrate benefit of dynamic splinting (LLPS) for extensor tendon repairs of the finger and for improving range of motion at the knee, elbow, wrist, and fingers. Small randomized controlled trials and prospective studies reported improved functional outcomes and ROM with dynamic splinting compared with static splinting or control treatments in these settings. Systematic reviews and pooled studies similarly support benefit of LLPS in these joints, while evidence is limited for other joints (shoulder, foot) and does not establish superiority or sufficient support for SPS or PASS devices.

Term	Definition
LLPS
Low-load prolonged-duration stretch device, also referred to as dynamic splinting; permits resisted active and passive motion using elastic traction (springs) to maintain tension.
SPS
Static progressive stretch device; holds joint in set position with manual modification of angle; does not exert stress unless set at maximum ROM.
PASS
Patient-actuated serial stretch device; permits resisted motion via pneumatic/hydraulic systems adjusted by the patient; requires custom fitting.

Revision History

03/25code_additionLatest

Added new HCPCS codes E1803, E1804, E1807, E1808.

11/23criteria_revision

Added ankle to Criteria I and clarified that LLPS may be provided with or without adjunctive physical therapy; specified that Criteria I.B is for a rental.

prior revisions (combined historical notes)policy_structure_change

Combined sections and replaced 'experimental/investigational' verbiage with descriptive language; removed SPS and PASS from medically necessary group and described them as not supported by current research.