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    v1.0.28
    OpenPayerPolicy UpdatesOrthopedics/Musculoskeletalnorthwood mechanical stretch devices Coverage | Op…
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    CurrentnorthwoodPolicy N/A

    Mechanical Stretch Devices for Contractures and Joint Stiffness

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    Defines medical necessity, coverage criteria, limitations, and exclusions for mechanical stretching devices (LLPS and SP) used to treat joint stiffness or contractures for Northwood members.

    Policy Summary
    Payernorthwood
    PolicyMechanical Stretch Devices for Contractures and Joint Stiffness
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateJan 1, 2020
    Last ReviewDec 8, 2025
    Next Review DateAug 12, 2025
    Key ActionOrder device and document indication and improvement in range of motion to justify initial and continued coverage.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    up to 4 monthsauthorized duration (knee/elbow/wrist/finger)

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    rentalbilling designation
    listedHCPCS codes
    not coveredPASS devices
    ROM improvementcontinued use contingent on

    Coverage Criteria

    Covered Indications (LLPS/SP)

    Covered when ALL of the following are met

    Basic ordering: Must be ordered by the member's treating practitioner.
    Indications for LLPS or SP devices: LLPS or SP devices are considered reasonable and necessary for the knee, elbow, wrist or finger for a period up to four (4) months for ANY of: (a) as part of a structured rehabilitative program for persistent joint stiffness in a subacute injury or following surgery; (b) in the acute postoperative period following surgery to improve the range of motion of a previously affected joint; (c) treatment for loss of motion from a contracture when formal rehabilitation is not feasible or has failed.up to 4 months

    Devices limited to knee, elbow, wrist, or finger.

    Ankle device: The Dynamic Adjustable Ankle Extension/Flexion device (JAS Ankle) is considered medically necessary for the treatment of contractures.
    Continued use is considered medically necessary when documented improvement in range of motion is shown.documented improvement in ROM

    Medical necessity condition

    Covered when ALL of the following are met

    Documented improvement: Mechanical stretching devices are considered medically necessary when documented improvement in range of motion is shown.documented improvement in ROM

    Continued use contingent on demonstrated ROM improvement

    The use of low-load prolonged stretch (LLPS) and static progressive (SP) devices is not considered reasonable and necessary for joints or conditions other than the knee, elbow, wrist, or finger. Examples of excluded sites include the foot/toe (HCPCS E1830, E1831), shoulder (HCPCS E1840, E1841), and ankle (HCPCS E1815, E1816). These uses are considered experimental, investigational, or unproven and therefore excluded from coverage. Other excluded conditions specifically listed include cerebral palsy, rheumatoid arthritis, and plantar fasciitis.

    Mechanical stretching is considered experimental, investigational, or unproven for certain indications and device types where evidence is insufficient. Examples cited in the policy include dynamic splinting for hallux valgus, the Medi-Dyne Prostretch device, Kinovo mechanical mobile arm supports, SaeboMas dynamic mobile arm supports, and the use of mechanical stretching for treatment of skin graft contracture. These specific indications and devices are not supported by adequate published evidence and are therefore excluded from coverage.

    The use of patient-actuated serial stretch (PASS) devices (for example, ERMI Extensionators/Flexionators for knee, ankle, shoulder, or elbow) is considered not reasonable and necessary for any indication because these devices are regarded as experimental, investigational, and/or unproven.

    Specific named devices and device types are considered experimental, investigational, or not medically necessary when there is inadequate evidence of clinical effectiveness for the indicated condition. The policy explicitly identifies examples such as dynamic splinting for hallux valgus, the Medi-Dyne Prostretch device, Kinovo and SaeboMas mobile arm support systems, and mechanical stretching for skin graft contracture as lacking sufficient evidence to support coverage.

    Coding

    HCPCS Level II Codes (selected from list)HCPCS
    E1800Dynamic adjustable elbow extension/flexion device, includes soft interface material.
    E1801Bi-directional static progressive stretch elbow device with range of motion adjustment, includes cuffs.
    E1802Dynamic adjustable forearm pronation/supination device, includes soft interface material.
    E1805Dynamic adjustable wrist extension/flexion device, includes soft interface material.
    E1806Bi-directional static progressive stretch wrist device with range of motion adjustment, includes cuffs.
    HCPCS Level II Codes (continued)HCPCS
    E1810Dynamic adjustable knee extension/flexion device, includes soft interface material.
    E1811Bi-directional static progressive stretch knee device with range of motion adjustment, includes cuffs.
    E1812Dynamic knee extension/flexion device with active resistance control.
    E1815Dynamic adjustable ankle extension/flexion device, includes soft interface material.
    E1816Bi-directional static progressive stretch ankle device with range of motion adjustment, includes cuffs.
    E1818Bi-directional static progressive stretch forearm pronation / supination device with range of motion adjustment, includes cuffs.
    E1820Replacement soft interface material, dynamic adjustable extension / flexion device.
    E1821Replacement soft interface material/cuffs for bi-directional static progressive stretch device.
    E1825Dynamic adjustable finger extension/flexion device, includes soft interface material.
    E1830Dynamic adjustable toe extension/flexion device, includes soft interface material.
    1–10 of 12
    1/2
    Affected codesmixed
    affected codesplaceholder in this chunk indicating affected codes are referenced elsewhere in the full policy

    Provider Actions & Billing

    Prior Authorization

    Prior authorization / billing note — rental designation and HCPCS coding

    Prior authorization and billing: Mechanical stretch devices are designated as rental items and must be ordered by the member's treating practitioner. Bill using the listed HCPCS Level II codes (examples include E1800–E1806, E1810–E1816, E1818, E1820, E1821, E1825, E1830, E1840, E1841). The Dynasplint may be billed twice only when two distinct devices are used (e.g., one for flexion and one for extension); repairs are included in the rental fee and replacement is covered when there is a documented change in the member's physical condition.

    • Devices are considered rental (Limitations: item 1).
    • Dynasplint may be billed twice only when two distinct devices are used (Limitations: item 2).
    • Repair included in rental fee; replacement covered when documented change in condition (Limitations: items 3–4).
    • Must be ordered by the member's treating practitioner (Coverage criteria: item 1).
    Prior Authorization

    Prior authorization and ROM evidence required for medical necessity

    Prior authorization and medical necessity determinations for DMEPOS mechanical stretch devices require documentation showing improvement in range of motion; continued coverage is contingent on documented ROM improvement.

    Background

    Joint stiffness or contracture can occur after surgery, disease, or trauma and may be managed with therapies such as physical therapy, serial casting, continuous passive motion, or mechanical stretching devices. Mechanical stretch devices are categorized as LLPS (low-load prolonged stretch), static progressive (SP), and patient-actuated serial stretch (PASS), each using a different mechanism to apply stretch and thereby address loss of range of motion.

    Definitions

    Low-load prolonged duration stretch (LLPS) — examples
    DefinitionDevices that permit resisted active and passive motion using elastic traction with springs to maintain prescribed tension.
    ExamplesDynasplint System, Ultraflex, Pro-glide dynamic ROM devices, Advance Dynamic ROM devices.
    Typical useProvide low-load prolonged-duration stretch within a limited range to treat joint stiffness or contracture.
    Static progressive (SP) devices — definition & examples
    DefinitionDevices that hold the joint in a set position allowing manual modification of the joint angle; motion may be active without resistance and does not provide elastic traction.
    ExamplesJoint Active Systems (JAS) Static Progressive Stretch devices; JAS Pronation/Supination device.
    Policy Summary
    Payernorthwood
    PolicyMechanical Stretch Devices for Contractures and Joint Stiffness
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateJan 1, 2020
    Last ReviewDec 8, 2025
    Next Review DateAug 12, 2025
    Key ActionOrder device and document indication and improvement in range of motion to justify initial and continued coverage.
    SourceLink
    On This Page
    Coverage CriteriaCodingProvider Actions & BillingBackgroundDefinitions
    • Prior authorization is applied in the DMEPOS policy context and medical necessity for continued use requires documented improvement in ROM.
    • Coverage note: continued use considered medically necessary when documented improvement in ROM is shown.
    Note

    Mechanical stretching as part of structured rehabilitation or when rehab fails

    Mechanical stretching devices (LLPS or SP) are covered as part of a structured rehabilitative program, in the acute postoperative period to improve ROM, or when formal rehabilitation is not feasible or has failed; use should follow these indications and be time-limited (up to four months for knee, elbow, wrist, or finger).

    • Covered indications include: as part of a structured rehabilitative program for persistent joint stiffness; acute postoperative use to improve ROM; or when formal rehabilitation is not feasible or has failed.
    • Devices covered for knee, elbow, wrist, or finger for up to four (4) months.
    Step Therapy

    Step therapy — no explicit requirements

    No formal step-therapy algorithm is specified in the policy; mechanical stretching is positioned as an option within a rehabilitative program or when rehabilitation has not been feasible or effective.

    • Policy states mechanical stretching may be used as part of a structured rehabilitative program or when formal rehabilitation is not feasible or has failed.
    • No explicit step therapy requirements are listed.
    Documentation Required

    Ordering and documentation requirement — treating practitioner must order device

    Device must be ordered by the treating practitioner; documentation supporting the order must show the covered indication and, for continuation, show documented improvement in range of motion.

    • Requirement: device ordered by the member's treating practitioner (Coverage criteria: item 1).
    • Documentation must show indication consistent with covered indications and evidence of ROM improvement for continued use.
    • Coverage determinations remain subject to member contract and medical necessity requirements.
    Documentation Required

    ROM documentation requirement for continued coverage

    Documented improvement in range of motion is required to consider mechanical stretch devices medically necessary; lack of documented ROM improvement may lead to a determination that continued use is not medically necessary.

    • Continued use is considered medically necessary only when documented improvement in ROM is shown.
    • Absence of documented ROM improvement may result in denial or discontinuation of coverage.
    Denial Risk

    Use of PASS devices and excluded joints/conditions — high denial risk

    PASS devices (e.g., ERMI Extensionators/Flexionators) and LLPS/SP devices for excluded joints/conditions (examples: toe/foot HCPCS E1830/E1831, shoulder E1840/E1841, ankle E1815/E1816; cerebral palsy, rheumatoid arthritis, plantar fasciitis) are considered experimental/investigational and are not reasonable and necessary—coverage may be denied.

    • Use of PASS devices is considered not reasonable and necessary for any indication (chunk 8).
    • Policy lists exclusions for certain joints and conditions (foot/toe, shoulder, ankle) with example HCPCS codes.
    • Named devices/systems (Medi-Dyne Prostretch, Kinovo, SaeboMas, carpal tunnel stretch systems, dynamic splinting for hallux valgus) are considered experimental/investigational.
    Denial Risk

    Denial risk if no documented ROM improvement

    Denial risk: continued coverage may be denied if there is no documented improvement in range of motion demonstrating medical necessity for the device.

    • Policy note: continued use is contingent on demonstrated improvement in ROM; lack of documented improvement may be determined not medically necessary.
    Typical useAllow limited passive or active motion with angle adjustment to address joint limitation without continuous elastic tension.
    Patient-actuated serial stretch (PASS) — examples
    DefinitionDevices using pneumatic systems adjusted by the patient to provide a low-to-high level load to the joint.
    ExamplesERMI Knee Extensionator; ERMI Knee/Ankle Flexionator; ERMI Shoulder Flexionator; ERMI MPJ Extensionator; ERMI Elbow Extensionator.
    User controlPatient adjusts pneumatic Extensionator/Flexionator systems to modulate applied load.
    Mechanical stretch devices / dynamic devices — evaluated examples & conditions
    ScopeDevices intended to provide mechanical stretching to treat contractures and joint stiffness; individual devices may be evaluated for evidence of effectiveness.
    Examples evaluated as experimental/investigationalMedi-Dyne Prostretch; Kinovo mechanical mobile arm support; SaeboMas dynamic mobile arm support; dynamic splinting for hallux valgus.
    Coverage conditionContinued use considered medically necessary only when documented improvement in range of motion is shown.