Currentjohns_hopkins_health_plansPolicy CMS19.07

Stretching Devices for the Treatment of Joint Stiffness and Contracture

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Policy governing coverage and medical necessity criteria for low-load prolonged-duration stretch (LLPS)/dynamic and static progressive stretch (SPS) splinting devices and patient-actuated serial stretch (PASS) devices for members of Johns Hopkins Health Plans participating organizations.

Policy Summary

Payerjohns_hopkins_health_plans

PolicyStretching Devices for the Treatment of Joint Stiffness and Contracture

Policy CodePolicy CMS19.07

Change TypeNo material change

Effective DateOct 1, 2025

Last ReviewOct 1, 2025

Next Review Date

Key ActionFor knee device coverage, include a current physician prescription and a clinical note documenting date of injury/surgery/diagnosis, previous treatments attempted, and a treatment plan including proposed duration of use.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

E18xx

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Currentjohns_hopkins_health_plansPolicy CMS19.07

Stretching Devices for the Treatment of Joint Stiffness and Contracture

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Sign up for johns_hopkins_health_plans Policy CMS19.07 alerts

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Policy Summary

Payerjohns_hopkins_health_plans

PolicyStretching Devices for the Treatment of Joint Stiffness and Contracture

Policy CodePolicy CMS19.07

Change TypeNo material change

Effective DateOct 1, 2025

Last ReviewOct 1, 2025

Next Review Date

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

E18xx

HCPCS device codes listed

4 monthsContinuation review threshold

3Device types described

SeveralNon-covered indications

Coverage and Medical Necessity Criteria

Medically Necessary Criteria

Covered when ALL of the following are met (plan benefits permitting):

General: When benefits are provided under the member's contract, LLPS/dynamic and static progressive stretch (SPS) splinting devices are considered medically necessary durable medical equipment when the criteria below are met.

Upper extremities: For the upper extremities (elbow, finger, and wrist): InterQual® criteria are met.

Knee - covered indications and documentation: For the knee: ONE of the specified clinical indications is present AND ALL documentation requirements are met.

Children: see exclusions for cerebral palsy exception only as adjunct to botulinum toxin.

Knee condition a: As an adjunct to physical therapy in the sub-acute injury or post-operative period (> 3 weeks but < 4 months after injury or operation) in patients with signs and symptoms of persistent joint stiffness.> 3 weeks and < 4 months

Knee condition b: In the acute post-operative period, for patients who are undergoing additional surgery to improve the range of motion of a previously affected joint.acute post-operative

Knee condition c: As an adjunct to botulinum toxin injections for conservative treatment of spasticity (considered on a case-by-case basis).case-by-case

Knee documentation requirements: Documentation must include: a current physician prescription AND a clinical note that documents the date of injury/surgery/established diagnosis, previous treatment attempted, and a treatment plan including proposed duration of use.

Continuation: Requests for continued dynamic or static splinting beyond 4 months for any listed condition may receive individual consideration when accompanied by medical records, a plan of care, and supporting peer‑reviewed medical literature.> 4 months

Unless the member's contract specifically provides benefits, Johns Hopkins Health Plans considers the use of low‑load prolonged‑duration stretch (LLPS)/dynamic and static progressive stretch (SPS) splinting devices to be experimental and investigational for indications that do not meet the policy's medical necessity criteria. When benefits are provided under the member's contract and the documented criteria in this policy are satisfied, LLPS/dynamic and SPS devices are considered medically necessary durable medical equipment for the specified indications.

Johns Hopkins Health Plans considers patient‑actuated serial stretch (PASS) devices (for example, ERMI flexionators/extensionaters) to be experimental and investigational for treatment of joint stiffness unless specific contract benefits apply, because they do not meet the Technology Evaluation Criteria.

Where applicable, state regulatory guidance (e.g., COMAR) or TRICARE criteria take precedence over this Johns Hopkins Health Plans medical policy. If no applicable state or TRICARE criteria exist, the Medical Policy criteria apply.

No additional explicit coverage exclusions beyond those listed in this policy extract are stated in the provided material.

Management of chronic joint stiffness and/or chronic or fixed contractures is considered experimental and investigational by Johns Hopkins Health Plans unless specific benefits are provided under the member's contract; such use does not meet the Technology Evaluation Criteria outlined in this policy.

No explicit statements labeled 'not medically necessary' are present in the provided document excerpts.

Coding and Timeframes

Informational CPT/HCPCS notemixed

No codes listed

HCPCS codes listedHCPCS

E1800	Dynamic adjustable elbow extension/flexion device, includes soft interface material.
E1801	Static progressive stretch elbow device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories.
E1802	Dynamic adjustable forearm pronation/supination device, includes soft interface material.
E1805	Dynamic adjustable wrist extension/flexion device, includes soft interface material.
E1806	Static progressive stretch wrist device, flexion and/or extension, with or without range of motion adjustment.
E1810	Dynamic adjustable knee extension/flexion device, includes soft interface material.
E1811	Static progressive stretch knee device, extension, and/or flexion, with or without range of motion adjustment, includes all components and accessories.
E1812	Dynamic knee, extension/flexion device with active resistance control.
E1815	Dynamic adjustable ankle extension/flexion device, includes soft interface material.
E1816	Static progressive stretch ankle device, flexion and/or extension, with or without range of motion.

1–10 of 18

1/2

Sub-acute post‑operative / injury window key

Typical sub-acute window> 3 weeks but < 4 months after injury or operation

Clinical contextApplied as an adjunct to physical therapy for patients with persistent joint stiffness in the sub-acute post‑injury or post‑operative period

Knee-specific noteThis window applies to knee indications listed under policy section IV.A.2.a

Documentation linkageCoverage during this window requires the documentation elements listed (current physician prescription; clinical note with date of injury/surgery/diagnosis; previous treatments; treatment plan and proposed duration)

Continuation review threshold

Authorization, Documentation, and Billing Actions

Prior Authorization

Pre-authorization required for all inpatient admissions

All inpatient admissions require pre-authorization.

Billing Rule

Use specified HCPCS E18xx codes on authorizations and claims

When seeking authorization or submitting claims for stretching devices or accessories, use the HCPCS codes listed in the policy (E1800–E1841, including replacement soft interface materials E1820 and E1821) to describe the device billed.

Examples include E1810/E1811 for knee dynamic/static devices and E1820/E1821 for replacement soft interface materials.

Clinical Background

Joint stiffness and contractures commonly arise after immobilization, surgery, trauma, or from neurologic and rheumatologic conditions. Mechanical stretching devices—described in this policy as LLPS/dynamic, static progressive stretch (SPS), and patient‑actuated serial stretch (PASS) devices—are used to apply prolonged passive or adjustable tension to restore range of motion and are commonly employed as adjuncts to conventional physical therapy in the post‑operative or post‑injury period. The policy notes stronger supporting evidence for LLPS (dynamic) devices for knee, elbow, wrist, and finger post‑injury or post‑operative stiffness and identifies the device classes and representative commercial examples cited in the literature and peer‑reviewed sources.

Definitions and Device Types

inv-26: Dynamic Splinting (LLPS) — definition and mechanism (elastic traction, allows active/passive motion)

DefinitionDynamic Splinting (LLPS): devices intended to restore range of motion by stretching joints using elastic traction; permit resisted active and passive motion and maintain a set level of tension via incorporated springs.

MechanismProvide low‑load prolonged‑duration stretch with elastic traction, allowing resisted active and passive motion within a limited range.

Examples (from background)Examples include Dynasplint Systems, StatA‑Dyne (dynamic models), Ultraflex, Pro‑Glide, DeROM, JAS Advance Dynamic Splints.

inv-27: Static Progressive Stretch (SPS) — definition: holds joint in set position with manual angle modification, allows active motion without resistance.

DefinitionStatic Progressive Stretch (SPS): devices that hold the joint in a set position with manual modification of joint angle and may allow active motion without resistance (inelastic traction).

Policy Summary

Payerjohns_hopkins_health_plans

PolicyStretching Devices for the Treatment of Joint Stiffness and Contracture

Policy CodePolicy CMS19.07

Change TypeNo material change

Effective DateOct 1, 2025

Last ReviewOct 1, 2025

Next Review Date

SourceLink

On This Page

Requests for continued dynamic or static splinting beyond 4 months may receive individual consideration

Required supporting materialsMedical records, a plan of care, and supporting peer‑reviewed medical literature must accompany requests beyond 4 months

Applies toAny condition listed in the medically necessary criteria when ongoing use exceeds 4 months

Decision basisIndividual consideration rather than automatic coverage — clinical rationale and evidence must be provided

Prior Authorization

No other prior authorization requirements specified

No additional prior authorization requirements beyond those stated in the policy text are specified in the provided document extracts.

Step Therapy

Knee devices must be adjunct to physical therapy in sub‑acute period

For knee indications, LLPS (dynamic) or SPS devices are covered only as an adjunct to physical therapy in the sub-acute post‑operative or injury period (>3 weeks but <4 months) when documentation requirements are met.

Covered as adjunct to physical therapy in sub‑acute window: >3 weeks but <4 months after injury/operation.
Also may be considered as adjunct to botulinum toxin on a case‑by‑case basis per policy.

Step Therapy

No step therapy requirements described

No step therapy requirements are described in the provided policy excerpts.

Documentation Required

Required clinical documentation for knee devices

For knee device coverage, include a current physician prescription and a clinical note documenting the date of injury/surgery/established diagnosis, previous treatments attempted, and a treatment plan including the proposed duration of device use.

Documentation Required

Documentation required for continuation beyond 4 months

Requests for continued use of dynamic or static splinting beyond 4 months require submission of medical records, a plan of care, and supporting peer‑reviewed medical literature for individual consideration.

Billing Rule

Document HCPCS E1800–E1841 (and E1820/E1821) on claims

Document the specific HCPCS device and accessory codes on claims; the policy lists E1800–E1841 and replacement soft interface materials E1820 and E1821 to describe billed devices.

List of codes in policy includes E1800, E1801, E1802, E1805, E1806, E1810, E1811, E1812, E1815, E1816, E1818, E1820, E1821, E1825, E1830, E1831, E1840, E1841.

Note

References and citations provided; no extra submission checklist noted

References and supporting citations are provided in the policy (peer‑reviewed literature and payer policy references); no additional submission checklist elements are specified in these extracts.

Examples cited: Sodhi et al. 2017; Svane et al. 2021; United Healthcare policy; additional peer‑reviewed studies.

Denial Risk

Policy adherence may be monitored — audit and post‑payment review risk

Adherence to the policy provisions may be monitored and addressed through post‑payment data analysis and/or medical review audits, creating audit and denial risk if documentation or coding does not support the medical necessity criteria.

Ensure documentation and coded claims align with policy criteria to mitigate post‑payment review risk.

Note

Follow applicable state/TRICARE regulatory guidance which supersedes this policy

When state regulations, COMAR guidance, or TRICARE guidance exist, those regulatory requirements supersede Johns Hopkins Health Plans Medical Policy; apply the Medical Policy criteria when no local rules or TRICARE policies exist.

Note

No explicit authorization/denial triggers stated

The provided policy excerpts do not specify explicit authorization or denial triggers beyond the stated coverage criteria and documentation requirements.

MechanismDo not exert stress on tissue unless joint angle is set at maximum ROM; allow incremental, manual angle adjustment to increase ROM.

Examples (from background)Examples include Stat‑A‑Dyne static splints, Static‑Pro devices, JAS SPS Systems.

inv-28: Patient-actuated Serial Stretch (PASS) — definition: pneumatic/hydraulic adjustable by patient to provide variable load.

DefinitionPatient‑actuated Serial Stretch (PASS): devices using pneumatic (extensionators) or hydraulic (flexionators) systems adjustable by the patient to provide a low‑ to high‑level load for resisted active and passive motion.

MechanismAdjustable pneumatic/hydraulic systems permit patient control of applied load to the joint over sessions.

ExamplesExamples include ERMI Knee/Elbow Extensionaters, ERMI Knee/Ankle Flexionater, ERMI Shoulder Flexionater.

inv-29: static progressive stretch device — coding-linked definition (examples: E1801, E1806, E1811, E1816, E1831, E1841).

Coding‑linked definitionStatic progressive stretch device: HCPCS examples include E1801, E1806, E1811, E1816, E1831, E1841 — described as static progressive stretch devices with or without ROM adjustment and including components/accessories.

Associated descriptionTypically coded when device holds joint in set position with adjustable angle (static progressive) for extension and/or flexion.

Documentation noteUse the listed HCPCS codes on claims to describe the static progressive stretch device billed.

inv-30: dynamic adjustable device — coding-linked definition (examples: E1800, E1802, E1805, E1810, E1812, E1815, E1825, E1830, E1840).

Coding‑linked definitionDynamic adjustable device: HCPCS examples include E1800, E1802, E1805, E1810, E1812, E1815, E1825, E1830, E1840 — described as dynamic adjustable devices that include soft interface material.

Associated descriptionTypically coded when device provides dynamic adjustable extension/flexion (or rotation/abduction) and includes soft interface material or active resistance control.

Documentation noteUse the listed HCPCS codes on claims to describe the dynamic adjustable device billed.

inv-31: replacement soft interface material — HCPCS E1820, E1821 defined as replacement soft interface material or cuffs.

HCPCS codesE1820 and E1821

DefinitionReplacement soft interface material or cuffs for dynamic adjustable extension/flexion devices (E1820) and for bi‑directional static progressive stretch devices (E1821).

Coding guidanceList replacement soft interface material codes on claims when billing for replacement cuffs or soft interface parts.

inv-32: Stretching device types — summary listing of static progressive, dynamic, and turnbuckle braces referenced in literature.

Static progressive (SPS)Devices that hold joint at set angle with manual adjustment to increase ROM (e.g., Stat‑A‑Dyne, Static‑Pro, JAS SPS).

Dynamic (LLPS)Low‑load prolonged‑duration stretch devices permitting resisted active/passive motion with elastic traction (e.g., Dynasplint, Ultraflex, Pro‑Glide).

Turnbuckle bracesTurnbuckle and related brace types are referenced in the literature for management of elbow, knee, and shoulder pathology and post‑traumatic elbow stiffness.