CurrentCentenePolicy CP.MP.144

Mechanical Stretching Devices for Joint Stiffness and Contracture

Defines coverage and medical necessity criteria for mechanical stretching devices (primarily low-load prolonged-duration stretch devices) used to treat joint stiffness and contracture for Centene-affiliated health plans; affects providers ordering/renting these devices and billing staff.

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 ActionObtain prior authorization for rental LLPS/dynamic stretch devices and document subacute timing, functional limitation, failure of conservative therapy, adjunctive treatment, and rental interval.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

IPrimary policy criteria section

E1800–E1832HCPCS codes referenced

knee, elbow, wrist, finger, toe, ankle, shoulderJoints discussed

≥20 refsEvidence cited

Coverage and Medical Necessity Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

LLPS/dynamic stretch device medical necessity

Covered when ALL of the following are met:

Overall: Request is for an LLPS device/dynamic stretch device for toe, knee, elbow, wrist, ankle, or finger and meets both sections A and B

Section I requires both A and B

I.A Indications: Requested for one of the following: (1) subacute injury or post-operative period (≥ three weeks and ≤ four months after injury or operation) with signs and symptoms of persistent joint stiffness or contracture AND all sub-conditions a–c; OR (2) acute post-operative period for members who have undergone additional surgery to improve the range of motion of the previously affected joint≥ 3 weeks and ≤ 4 months (for subacute indication)

Sub-conditions for I.A.1: a. Limited range of motion poses a meaningful functional limitation determined by the physician or therapist; b. Has not responded to other interventions (including physical therapy); c. Provided with adjunctive treatment along with requested device (eg, home exercise program, physical therapy)

I.B Rental requirement: Request is for a rental for one of the following: (1) an initial four weeks; OR (2) a subsequent four week period when improvement was noted upon reevaluation after the prior four week periodinitial 4 weeks; subsequent 4 week periods require documented improvement

Policy specifies rental-only coverage intervals

Devices or uses without support

Not supported/not recommended:

II.A: Use of LLPS for any indication not noted in section I is not supported by current research

See policy section II.A

II.B: Bi-directional static progressive stretch (SPS) devices are not supported over other currently available alternatives per current research

See policy section II.B

II.C: Patient-actuated serial stretch (PASS) devices are not supported by current research due to insufficient evidence of safety and efficacy

See policy section II.C

The policy identifies specific device types and uses that are not supported by current research and therefore are outside the scope of coverage. The HCPCS codes listed in the "do not support" table (e.g., E1399, E1801, E1806, E1811, E1816, E1818, E1831, E1832, E1840, E1841) are associated with static progressive stretch (SPS), miscellaneous DME, and shoulder devices and are described in the policy as not supporting coverage criteria for the indications defined in Section I.

The policy also states that there is insufficient evidence to support use of LLPS/dynamic stretch devices at joints outside those identified in Section I (notably the foot and shoulder) and that patient-actuated serial stretch (PASS) devices lack sufficient published evidence to demonstrate safety, efficacy, and long‑term outcomes. Requests for SPS or PASS devices, or for LLPS at unsupported joints, are therefore not supported by the policy's coverage criteria.

Coverage decisions under this clinical policy are intended as a guide to medical necessity and do not replace the terms of a member’s coverage documents. Actual coverage and benefit administration remain subject to all applicable terms, conditions, exclusions, and limitations of the member’s contract (for example, evidence of coverage, certificate of coverage, or policy), as well as state and federal requirements and Health Plan administrative policies.

The policy does not guarantee payment; providers should verify member eligibility, benefit specifics, and any plan‑level requirements or restrictions before ordering or billing for devices covered under these criteria.

Requests for static progressive stretch (SPS) or patient‑actuated serial stretch (PASS) devices, or for LLPS/dynamic stretch devices used for indications outside Section I, are described in the policy as not supported by current research and therefore not medically necessary under this policy. Providers submitting requests for these device types or unsupported indications should expect that such requests may be denied according to the policy.

For billing and coding purposes, the policy explicitly identifies HCPCS codes associated with non‑supported devices and uses (see the policy’s "do not support" HCPCS list). Use of those codes for indications outside the supported Section I criteria does not meet the medical necessity criteria outlined in the policy.

Coding and Timing

HCPCS codes that support 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 only device, includes soft interface material
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

1–10 of 21

1/3

HCPCS codes that do not support coverage criteriaHCPCSNot 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
E1832	Static progressive stretch finger device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories
E1840	Dynamic adjustable shoulder flexion/abduction/rotation device, includes soft interface material
E1841	Static progressive stretch shoulder device, with or without range of motion adjustment, includes all components and accessories

inv-08: subacute timing window — ≥ 3 weeks and ≤ 4 months after injury or operation

Subacute timing windowRequests for LLPS/dynamic stretch devices are eligible when requested in the subacute injury or post-operative period: ≥ 3 weeks and ≤ 4 months after injury or operation.

Applicable jointsToe, knee, elbow, wrist, ankle, or finger (device must be for one of these joints).

Clinical prerequisitesPersistent joint stiffness/contracture with limited ROM that poses a meaningful functional limitation determined by a physician or therapist.

Prior interventionsHas not responded to other interventions, including physical therapy.

Adjunctive treatmentDevice must be provided with adjunctive treatment such as a home exercise program or physical therapy.

Prior Authorization, Documentation, and Provider Responsibilities

Prior Authorization

Prior Authorization Required

Prior authorization is required for rental low-load prolonged-duration stretch (LLPS)/dynamic stretch devices. Requests must document indication, timing, functional limitations, and prior conservative therapy. Providers should submit clinical notes that demonstrate the device meets the policy criteria (see policy/criteria Section I) and that conservative measures such as physical therapy have been attempted without adequate improvement.

Prior authorization required for rental devices (initial 4 weeks; subsequent 4-week rentals require demonstrated improvement)
Affected HCPCS (supported): E1800, E1802, E1803, E1804, E1805, E1807, E1808, E1810, E1812, E1813, E1814, E1815, E1820, E1822, E1823, E1825, E1826, E1827, E1828, E1829
Do not support coverage for: E1399 and listed static progressive stretch (SPS) codes and other codes in the 'do not support' list — requests for these may be denied

Documentation Required

Required Clinical Documentation

Documentation must support the medical necessity elements: the specific affected joint and indication (subacute or specified post-operative timing or acute revision surgery), objective or clinician-determined meaningful functional limitation, failure to improve after conservative care (for example, a course of physical therapy), and adjunctive treatments planned or provided (home exercise program, therapy, etc.). Include reevaluation notes when requesting continuation rentals showing improvement after the prior rental period.

Include dates of injury/operation and dates of physical therapy or other conservative care
Describe functional limitation and measurement of range of motion or clinician assessment
For continuation rentals, provide documentation of improvement after the prior 4-week rental

Note

Coverage Subject to Plan Terms

Coverage is subject to the member's plan terms, conditions, exclusions, and limitations. Providers must exercise independent professional medical judgment; this policy is a guide and does not guarantee coverage or payment. For Medicaid members, state Medicaid provisions take precedence over this clinical policy when conflicts exist.

Coverage decisions are subject to the applicable evidence of coverage or certificate of coverage
When state Medicaid rules conflict with this policy, state provisions govern

Denial Risk

Denial Risk for Non‑Supported HCPCS

Requests for codes listed in the 'HCPCS codes that do not support coverage criteria' (e.g., E1399, E1801, E1806, E1811, E1816, E1818, E1831, E1832, E1840, E1841) are at high risk for denial. Submit clarifying documentation if an alternate supported HCPCS is intended.

If submitting E1399, include justification and attempt to use a specific supported HCPCS when possible
Static progressive stretch (SPS) and PASS devices are not supported per policy and will likely be denied

Note

Check Effective Date and Medicare/NCD/LCDs

Check the effective date of this clinical policy and review any applicable Medicare NCDs/LCDs or state-specific requirements before applying the criteria. If Medicare determinations or legal/regulatory requirements differ from this policy, the law and applicable CMS guidance govern.

Review CMS NCDs/LCDs/coverage articles at http://www.cms.gov for Medicare members
Confirm the Health Plan-effective date prior to authorization decisions

Clinical Background and Evidence Summary

A joint contracture is characterized by a chronic reduction in joint range of motion due to structural changes in non‑osseous tissues (for example, muscle, tendon, capsule, and periarticular connective tissue). Contractures commonly develop after prolonged immobilization, trauma, or surgery and can lead to persistent stiffness that limits function.

Mechanical stretching devices such as LLPS/dynamic stretch devices are intended to apply a controlled, low‑load prolonged stretch to periarticular tissues to gradually increase range of motion and improve function. The policy notes the strongest evidence for LLPS use is at the knee, elbow, wrist, and fingers, while evidence is insufficient for other joints (e.g., foot and shoulder); LLPS is used adjunctively with therapy and other conservative measures to address persistent joint stiffness following injury or surgery.

Device Definitions

inv-18: LLPS/dynamic splinting devices — maintain a set level of tension via springs and permit resisted active and passive motion within a limited range

DefinitionLLPS/dynamic splinting devices maintain a set level of tension by means of incorporated springs and permit resisted active and passive motion (elastic traction) within a limited range.

MechanismProvide low-load prolonged-duration stretch via springs to apply continuous tension over time.

Motion allowedPermits resisted active and passive motion within a limited range while maintaining set tension.

Typical useUsed post-operatively or after injury to treat joint stiffness and contracture at knee, elbow, wrist, finger, toe, or ankle.

inv-19: Static progressive stretch (SPS) — devices that hold the joint in a set position and allow manual modification of joint angle, providing inelastic traction

DefinitionStatic progressive stretch (SPS) devices hold the joint in a set position and allow manual modification of the joint angle, providing inelastic traction.

Stress characteristicsThese devices do not exert continuous stress on tissue unless the joint angle is set at the maximum range of motion.

FunctionAllow for active motion without resistance when adjusted; angle is manually incremented to increase ROM.

Evidence noteSPS has been studied (notably for elbow stiffness) but policy does not support SPS over other alternatives for indications outside specified criteria.

inv-20: Patient-actuated serial stretch (PASS) — devices using pneumatic or hydraulic systems adjusted by the patient

DefinitionPatient-actuated serial stretch (PASS) devices use pneumatic or hydraulic systems adjusted by the patient to permit resisted active and passive motion.

Systems usedExtension devices typically use pneumatic systems; flexion devices typically use hydraulic systems.

Fitting requirementThese devices require custom fitting.

Policy statusCurrent research does not support PASS devices over other available alternatives per the policy.

inv-21: Dynamic splinting — Mechanical devices applying continuous or cyclic low-load stretch to improve ROM and reduce contracture

DefinitionDynamic splinting refers to mechanical devices that apply a continuous or cyclic low-load stretch to joints to improve range of motion and reduce contracture.

Therapeutic goalImprove ROM and reduce joint contracture through prolonged low-load stretch, often used adjunctively with therapy.

Evidence summaryRandomized and observational studies evaluate dynamic splinting effectiveness for knee, elbow, wrist, and finger extensor tendon injuries; evidence is limited and joint-specific.

Device characteristicsOften synonymous with LLPS devices that maintain tension (e.g., via springs) and permit resisted motion within a limited range.

inv-22: Static progressive splinting — splinting approach applying progressively increased static stretch with adjustable components

DefinitionStatic progressive splinting is a splinting approach that applies progressively increased static stretch, often using adjustable components (e.g., turnbuckle orthosis).

MechanismProgressively increases static stretch by manually adjusting components to incrementally increase joint angle.

Clinical useDescribed in prospective studies for elbow stiffness and other joints; may allow active motion without resistance when set.

Policy contextPolicy notes SPS is not supported over other alternatives for indications outside section I.