Currentsierra health and lifePolicy 2026T0481BB

Medical Policy - Mechanical Stretching Devices

Defines UnitedHealthcare coverage position for mechanical stretching devices (LLPS, SPS, PASS) for treatment of joint contractures of the extremities for Commercial and Individual Exchange plans, including applicable HCPCS codes and evidence summary. This is Part 1 of 2 and includes policy rationale, evidence review, applicable codes, FDA info, and revision history.

Policy Summary

Payersierra health and life

PolicyMedical Policy - Mechanical Stretching Devices

Policy CodePolicy 2026T0481BB

Change TypeTemplate updatearchived prior versions

Effective DateJan 1, 2026

Next Review Date

Key ActionReference the member specific benefit plan document and applicable laws when determining coverage; medical records documentation may be required to assess clinical criteria for coverage.

SourceLink

POLICY UPDATE CHANGES

Template Update: Created shared policy version to support application to Oxford plan membership and archived previous policy version 2025T0481AA and DME 005.31.

Template Update - Created shared policy version to support application to Oxford plan membership.

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.

Coverage Summary

Defines UnitedHealthcare coverage position for mechanical stretching devices (LLPS, SPS, PASS) for treatment of joint contractures of the extremities for Commercial and Individual Exchange plans. Part 1 of 2: includes policy rationale, evidence review, applicable HCPCS/DME codes, FDA information, and revision history. Policy Number: 2026T0481BB. Effective Date: January 1, 2026.

Policy metadata

Policy number2026T0481BB

Effective dateJanuary 1, 2026

StatusCURRENT

PayerUnitedHealthcare Commercial and Individual Exchange

Scope summaryDefines UnitedHealthcare coverage position for mechanical stretching devices (LLPS covered as adjunct to therapy; SPS and PASS not medically necessary) for treatment of joint contractures of the extremities for Commercial and Individual Exchange plans; includes applicable HCPCS codes, evidence summary, FDA info, and revision history. Part 1 of 2.

Coverage stance: Mixed — LLPS (Low-load prolonged-duration stretch devices) are covered (proven and medically necessary as an adjunct to therapy for treating existing joint contractures of the upper and lower extremities). SPS (Static progressive stretch) and PASS (Patient-actuated serial stretch) devices are not medically necessary due to insufficient evidence of efficacy.

Medical-Necessity Criteria

Coverage Rationale

Coverage statements for device categories:

LLPS: Low-load prolonged-duration stretch devices (LLPS) as an adjunct to therapy are proven and medically necessary for treating existing joint contractures of the upper and lower extremities.

SPS: Static progressive stretch (SPS) splint devices are unproven and not medically necessary, alone or combined with standard physical therapy, for treating joint contractures of the upper and lower extremities due to insufficient evidence of efficacy.

PASS: Patient actuated serial stretch (PASS) devices (patient controlled mechanical stretching) are unproven and not medically necessary, alone or combined with standard physical therapy, for treating joint contractures of the upper and lower extremities due to insufficient evidence of efficacy.

General application

Applicable HCPCS / Referenced Codes

Applicable HCPCS / DME codes referencedHCPCS

E1399	Durable medical equipment, miscellaneous.
E1800	Dynamic adjustable elbow extension and flexion device, includes soft interface material.
E1801	Static progressive stretch/patient actualized serial stretch elbow device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories.
E1803	Dynamic adjustable elbow extension only device, includes soft interface material.
E1804	Dynamic adjustable elbow flexion only device, includes soft interface material.
E1806	Static progressive stretch wrist device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories.
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 and flexion device, includes soft interface material.
E1811	Static progressive stretch/patient actualized serial stretch knee device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories.

1–10 of 26

1/3

Referenced archived policiesmixed

2025T0481AA	Archived previous policy version
DME 005.31	Archived DME policy reference

Referenced archived policiesmixed

2025T0481AA	Archived previous policy version
DME 005.31	Archived DME policy reference

Provider Actions & Documentation

Documentation Required

Medical records documentation may be required

Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage; benefit coverage is determined by the member specific benefit plan document and applicable laws. Documentation does not guarantee coverage.

Documentation Required

Reference member-specific benefit plan

Providers must reference the member specific benefit plan document (and applicable federal/state mandates) when determining coverage because plan terms may differ from this standard policy; in the event of a conflict, the member specific benefit plan governs.

Documentation Required

Use evidence-based rationale for Medicare Advantage

When no Medicare NCD/LCD exists, Medicare Advantage Organizations (MAOs) may create coverage determinations using objective evidence-based rationale and authoritative evidence; document the rationale if applying this policy to Medicare Advantage members.

Background & Evidence Summary

Mechanical stretching devices (dynamic splinting systems) are used to prevent and treat joint contractures by providing controlled joint mobilization to maintain or restore joint range of motion. The policy groups devices into three categories: LLPS (low-load prolonged-duration stretch or dynamic splinting systems used often during rest/sleep), SPS (static progressive splints that hold a joint at a set position with manual angle adjustment and do not exert continuous motion stress), and PASS (patient-actuated serial stretch devices that use pneumatic or hydraulic loading adjusted by the patient). The evidence summary states that LLPS devices have demonstrated effectiveness for certain joints (finger, wrist, elbow, knee, toes) in some trials and reviews, whereas SPS and PASS lack sufficient evidence in the published literature to demonstrate safety and efficacy for treating joint contractures.

Evidence source	Summary / relevance
Hayes technology report	Hayes review (2018, updated 2022) concluded evidence insufficient for SPS, PASS, or LLPS for indications other than finger extensor injury; noted fair-to-low quality studies, small benefits in ROM with LLPS but limited clinical meaningfulness and paucity of studies for many joints.
Randomized controlled trials / Systematic reviews	Multiple RCTs and systematic reviews cited: some RCTs and systematic reviews show LLPS (dynamic) benefits for certain joints (finger, wrist, elbow, knee, toes) while overall evidence is mixed; systematic reviews report variable results and methodological limitations.
Pilot feasibility cohort comparison	Pilot feasibility study (Rauzi et al. 2022) of multimodal PT including static progressive splinting for arthrofibrosis after TKA showed feasibility with similar ROM outcomes to manipulation under anesthesia in a small retrospective comparison; limited by small size and design.
Prospective randomized trial / systematic review evidence (LLPS lower extremity)	Systematic review (Furia et al. 2013) and prospective trials indicate dynamic splinting with prolonged passive stretching can improve lower extremity ROM and that hours of stretching correlate with AROM gains; evidence supports LLPS efficacy for some lower-extremity contractures but quality and generalizability vary.
Randomized controlled trial - adhesive capsulitis	Teytelbaum et al. (2024) RCT comparing at-home high-intensity stretch device to PT (and combined) in adhesive capsulitis found greater ROM restoration and improved patient-reported scores with the device; authors noted limitations and need for further investigation.
Systematic review - posttraumatic elbow stiffness	Veltman et al. (2015) systematic review found both SPS and dynamic splinting produced good results for elbow stiffness; post-splinting ROM slightly favored SPS in included studies, but choice depends on clinician/patient preference and evidence base is limited.

Definitions

LLPS: Low-load prolonged-duration stretch devices (dynamic splinting systems) designed to provide prolonged passive stretch often during rest or sleep.

Also called dynamic splinting; used for finger, wrist, elbow, knee, ankle, toes; may be prefabricated or custom.

SPS: Static progressive stretch devices (splints) that hold the joint in a set position allowing manual modification of angle; do not exert continuous stress for active or passive motion.

Also described as inelastic traction; allow manual angle adjustment.

Medicare Determinations

When making coverage decisions, the member-specific benefit plan governs and medical records documentation may be required to assess whether clinical criteria are met. In the absence of a Medicare NCD/LCD, Medicare Advantage Organizations (MAOs) may create their own coverage determinations using objective evidence-based rationale; the brief does not list a Medicare effective date or number for a Medicare NCD (fields empty) and advises that rationale should be documented when applying this policy to MA members.

Revision History

01/01/2026Template UpdateLatest

Template Update: Created shared policy version to support application to Oxford plan membership and archived previous policy version 2025T0481AA and DME 005.31.

Prior to 01/01/2026Archived previous policy version

Archived previous policy version 2025T0481AA and DME 005.31 (prior policy references archived during template update).