CurrentCentenePolicy CP .MP.144

Mechanical Stretching Devices for Joint Stiffness and Contracture

Defines medical necessity and coverage criteria for mechanical stretching devices (LLPS/dynamic stretch, SPS, PASS) used to prevent or treat joint stiffness and contracture in members/enrollees, and lists supporting and non-supporting HCPCS codes. Applies to Centene-affiliated health plans.

Policy Summary

PayerCentene

PolicyMechanical Stretching Devices for Joint Stiffness and Contracture

Policy CodePolicy CP .MP.144

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit rental and procurement requests with the applicable HCPCS code(s) and documentation showing failed conservative therapy and persistent functional limitation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

knee, elbow, wrist, ankle, fingermedically necessary indications

PASS & SPSdevices not supported

16HCPCS codes listed

~19references cited

Coverage and Medical Necessity Criteria

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LLPS (dynamic stretch device) - Medically Necessary Rental Criteria

Covered when ALL of the following are met:

Timing and indication: Member is in the subacute injury or post-operative period (3 weeks to <4 months after injury or operation) with symptoms and signs of persistent joint stiffness or contracture; OR in the acute post-operative period when undergoing additional surgery to improve range of motion of the previously affected joint.timing: 3 weeks to <4 months

Supports rental for an initial 4-week period and a subsequent 4-week period if improvement is noted upon reevaluation.

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

Failure of other therapy: Has not responded to other therapy (including physical therapy).prior conservative therapy failed

Prior conservative therapy must have been tried and failed prior to LLPS rental coverage in the subacute period.

Adjunctive therapy: Device may be provided with or without adjunctive physical therapy.optional adjunctive PT

Device term: Request is for a rental: initial 4 weeks; may extend for a subsequent 4-week period if improvement is noted upon reevaluation after the initial 4-week period.rental periods specified

Coding and Billing

HCPCS codes supporting coverage criteriaHCPCSCovered

E1800	Dynamic adjustable elbow extension/flexion device; includes soft interface material.
E1802	Dynamic adjustable forearm pronation/supination device, includes soft interface.
E1803	Dynamic adjustable elbow extension only device, includes soft interface material.
E1804	Dynamic adjustable elbow flexion only device, includes soft interface material.
E1805	Dynamic adjustable wrist extension/flexion device, includes soft interface material.
E1807	Dynamic adjustable wrist extension device, includes soft interface material only.
E1808	Dynamic adjustable wrist flexion only device, includes soft interface material.
E1810	Dynamic adjustable knee extension/flexion device, includes soft interface material.
E1812	Dynamic_knee_extension/flexion device_with active _resistance control.
E1813	Dynamic adjustable knee extension only device, includes soft interface material.

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HCPCS codes that do not support coverage criteria / static progressive or miscellaneousHCPCSNot 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 O 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 O without range f 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_

ICD-10 codes referenced in revision historyICD-10

M24.521	Diagnostic/ICD-10 code referenced in policy (included in revision history).
M24.529	Diagnostic/ICD-10 code referenced in policy (included in revision history).
M24.531	Diagnostic/ICD-10 code referenced in policy (included in revision history).
M24.539	Diagnostic/ICD-10 code referenced in policy (included in revision history).
M24.541	Diagnostic/ICD-10 code referenced in policy (included in revision history).
M24.549	Diagnostic/ICD-10 code referenced in policy (included in revision history).
M24.561	Diagnostic/ICD-10 code referenced in policy (included in revision history).
M24.569	Diagnostic/ICD-10 code referenced in policy (included in revision history).
M25.621	Diagnostic/ICD-10 code referenced in policy (included in revision history).
M25.629	Diagnostic/ICD-10 code referenced in policy (included in revision history).

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Timing window for subacute LLPS

Timing windowSubacute period: 3 weeks to <4 months after injury or operation

Alternative acute indicationAcute post-operative period when additional surgery to improve ROM of previously affected joint

Rental term - initialInitial rental for 4 weeks

Rental term - extensionMay extend for a subsequent 4-week period if improvement noted upon reevaluation after the initial 4 weeks

Documentation requirementDocumentation must show persistent joint stiffness/contracture and failure of other therapy, supporting timing within the window

Provider Responsibilities, Documentation, and Authorization

Billing Rule

HCPCS Code Requirements

Rental and procurement requests should be submitted with the applicable HCPCS code(s). Use the LLPS/dynamic device HCPCS codes listed below to support coverage determinations; requests billed to miscellaneous or unsupported codes risk denial or recoupment.

Submit the specific HCPCS code that matches the device and anatomic site.
Do not submit requests under E1399 (DME miscellaneous) when a specific LLPS HCPCS exists.

Prior Authorization

Prior Authorization Governed by Plan Documents

Prior authorization requirements are governed by the member's plan documents. This clinical policy is intended to guide medical necessity determinations but does not replace the member's certificate of coverage or plan-specific prior authorization rules.

Verify prior authorization rules, submission portals, and timelines in the member's plan or applicable provider manual.
If plan-level prior authorization is required, submit all required clinical documentation as part of that request.

Denial Risk

Denial Risk from Plan Exclusions/Limitations

Coverage determinations are subject to all terms, conditions, exclusions and limitations of the member's coverage document. Requests inconsistent with the contract, state Medicaid rules, or other program requirements may be denied even if they meet this clinical guidance.

Confirm eligibility and benefit coverage prior to device procurement or rental.
State Medicaid provisions or other regulatory requirements may supersede this policy.

Documentation Required

Required Clinical Documentation

Providers must submit documentation that supports the indication, timing, and prior conservative therapy attempts. Documentation should be sufficient to allow clinical review of medical necessity for the requested LLPS device.

Clinical note describing diagnosis, affected joint, and measurable functional limitation.
Operative report or injury date to establish timing (subacute period: >3 weeks and <4 months post-injury/operation where applicable).
Records of prior conservative care (e.g., dates and notes for supervised physical therapy, splinting, medications) and statement that conservative therapy failed to achieve adequate range-of-motion improvement.
Documentation of trial rental period results and clinician re-evaluation notes if continuing rental is requested.

Documentation Required

Documentation and Contractual Obligations

Providers are bound by their contractual obligations to submit accurate claims and supporting documentation. Failure to submit required documentation or submission of incorrect codes may result in denial, recoupment, or breach of contract. Where applicable, state Medicaid provider requirements take precedence.

Submit claims using the appropriate HCPCS code and modifiers as required by the payer.
Maintain contemporaneous medical records supporting the medical necessity determination and make them available upon request.
Adhere to all contractual and state program billing rules; disputed coverage decisions may follow the plan's appeals process.

Step Therapy

Conservative Therapy Prerequisite

Prior conservative therapy must have been tried and failed prior to rental coverage for LLPS in the subacute period. Conservative care includes supervised physical therapy and other non-operative interventions aimed at improving range of motion.

Document at least one course of conservative therapy (for example, supervised physical therapy) with dates and objective assessments showing inadequate improvement.
If the request is for the acute post-operative period following additional surgery to improve range of motion, document the surgical indication and the postoperative timeline.
Requests without evidence of prior conservative therapy when required are subject to denial.

Definitions

Low-load prolonged-duration stretch (LLPS)

DefinitionDevices that permit resisted active and passive motion using elastic traction and maintain a set level of tension via incorporated springs (also referred to as dynamic splinting).

Motion characteristicsAllows resisted motion within a limited range using elastic (spring) traction, supporting both active and passive movement.

Common use sitesEvidence strongest for knee, elbow, wrist, and finger extensor tendon injuries

ProvisionMay be provided with or without adjunctive physical therapy when medically necessary

Static progressive stretch (SPS)

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

MechanismDoes not exert stress on tissue unless the joint angle is set to a maximum—stretch is applied by changing the set angle rather than continuous elastic tension.

Evidence noteSome evidence supports SPS use at the elbow; overall research is limited compared with LLPS for certain joints.

Patient-actuated serial stretch (PASS)

DefinitionDevices that permit resisted active and passive motion within a limited range using pneumatic or hydraulic systems that are adjustable by the patient; typically require custom fitting.

System typesExtension devices generally use pneumatic systems; flexion devices generally use hydraulic systems.

Evidence statusCurrent research does not support PASS devices compared with alternatives; insufficient evidence for broad coverage.

dynamic splinting / static progressive splinting

DefinitionMechanical devices (dynamic splinting and static progressive splints) used to apply stretching forces to reduce joint stiffness and contracture.

Relation to studiesMultiple peer-reviewed studies cited: dynamic splinting evaluated after knee surgery and for hand/wrist stiffness; some RCTs show mixed results (e.g., Jongs et al. 2012 found no reduction in contracture after distal radial fracture).

SPS evidenceRecent evidence includes evaluation of static progressive Joint Active System improving upper extremity stiffness (Steinberg et al., 2024).

Clinical implicationEvidence is strongest for LLPS at knee, elbow, wrist, and finger; SPS has some support at the elbow; dynamic splinting literature is mixed across indications.

OpenPayer

Mechanical Stretching Devices for Joint Stiffness and Contracture

Coverage and Medical Necessity Criteria

Coding and Billing

Provider Responsibilities, Documentation, and Authorization

Background

Definitions