Prior authorization and rental: initial 4-week rental; subsequent rental requires documented improvement

Prior authorization is implied for device requests; rental requests must specify an initial four-week rental and any subsequent four-week rental only after documented improvement on reevaluation following the prior four-week rental.

• Initial rental: one four-week period.
• Subsequent rental: additional four-week period only if improvement was noted on reevaluation after the prior four-week period.

Prior authorization: verify HCPCS code is in the 'supports coverage' list

Prior authorization is implied where the policy defines medical necessity for specific HCPCS codes; the policy lists codes that support coverage (e.g., E1800, E1802, E1805, E1810, E1812, E1828, E1829, E1830/E1832) and a separate list of codes that do not support coverage, so confirm the requested HCPCS matches the 'supports coverage' table before submitting.

• Use codes from the 'HCPCS codes that support coverage criteria' table (chunk 13 / code group additions in chunks 18,21).
• Do not submit requests using HCPCS codes listed in the 'does not support coverage criteria' table (chunks 16,19) unless policy has been updated to move the code.

Therapy prerequisite: document nonresponse to other therapy (including PT)

Document that the member has not responded to other therapy, including physical therapy, before requesting authorization for LLPS or SPS devices; lack of response to prior therapy is a required medical necessity element.

• Explicit statement that prior conservative therapy (including number of PT sessions and duration) failed to achieve adequate range-of-motion improvement.
• If adjunctive therapy is provided with the device, note whether it was provided with or without adjunctive physical therapy as specified by device criteria.

Provider action: identify device, joint, and criteria being met on the request

Ensure the request clearly identifies the device type, anatomical joint, and whether the request is for rental versus purchase, and reference the specific policy criteria being met (e.g., Criteria I.A–I.B for LLPS or Criteria II for SPS).

• Specify joint (toe, knee, elbow, wrist, ankle, finger) and cite the applicable policy criterion.
• Indicate rental duration requested (initial four weeks or subsequent four weeks with documented improvement).

Required documentation: timing, functional limitation, and therapy history

Provide documentation showing timing relative to the injury or surgery (subacute defined as ≥ three weeks and ≤ four months), the presence of a meaningful functional limitation, prior therapy history and response, and whether adjunctive treatments were provided with the device.

• Date of injury or operation to demonstrate timing (≥3 weeks and ≤4 months for subacute criteria).
• Clinician assessment that limited ROM poses a meaningful functional limitation.
• Records of prior therapies (type, duration, and objective response).
• Description of adjunctive treatment provided (home exercise, PT, etc.).

Documentation and regulatory alignment: follow policy criteria and enrollment contract/regulations

Document medical necessity using the policy's clinical criteria and follow any applicable coverage provisions in the enrollment contract; state Medicaid or Medicare NCD/LCD requirements take precedence if discrepant.

• Reference the policy criteria when documenting clinical indications and necessity.
• If state Medicaid or federal requirements conflict with this policy, follow the applicable regulatory requirement.

Denial triggers: not meeting medical necessity or wrong device/indication

Expect denials for requests that do not meet the medical necessity criteria (e.g., LLPS/SPS/PASS for indications outside those listed) or when the submitted HCPCS code is listed as not supporting medical necessity.

• Requests for LLPS for joints not listed in Criteria I or for PASS devices may be denied as not supported.
• Requests using HCPCS codes from the 'does not support' table are at risk for denial.

Coding-based denial risk: avoid HCPCS codes listed as not supporting medical necessity

Using HCPCS codes that the policy lists as 'does not support medical necessity' (e.g., E1399, E1801, E1806, E1811, E1816, E1818, E1831, E1832, E1840, E1841) may result in claim denial; note that codes have been reclassified between supporting and not-supporting lists, so verify the current table before billing.

• Confirm the code is on the current 'supports coverage' list — several codes were moved (for example, E1815 moved to the supporting list per revisions).
• Do not submit claims with codes still listed in the 'does not support' table without prior authorization and clear documentation linking to policy criteria.