Mechanical Stretching Devices (for Kansas Only)

Coverage Summary

Overview: This UnitedHealthcare Community Plan medical policy (Policy Number: CSO77KS.02, Effective Date: August 1, 2025) applies only to the state of Kansas and governs coverage rationale, clinical criteria references, and billing code guidance for mechanical stretching devices used to prevent or treat joint contractures of the upper and lower extremities. The policy stance is mixed: some device types are considered proven/medically necessary in defined situations while others are considered unproven/not medically necessary.

Device categories (high level):

- LLPS (Low-load prolonged-duration stretch devices): dynamic splinting systems intended to provide prolonged, low-load stretch to maintain or restore range of motion (ROM). Considered proven and medically necessary in certain circumstances as adjuncts to therapy when not addressed by InterQual criteria.

- SPS (Static progressive stretch) devices: splints that hold a joint in a set position and allow manual angle modification; considered unproven and not medically necessary for treating joint contractures of the upper and lower extremities.

- PASS (Patient-actuated serial stretch) devices: patient-controlled mechanical stretching devices; considered unproven and not medically necessary due to insufficient evidence.

High-level coverage stance summary: LLPS—proven/medically necessary in specified circumstances (including as an adjunct when InterQual does not address the indication); SPS and PASS—unproven and not medically necessary for upper and lower extremity joint contractures.

Policy facts

Device categories discussedLLPS, SPS, PASS

Joints with supportive evidence for LLPSFinger, wrist, elbow, knee, toe

Devices designated not medically necessaryStatic progressive stretch (SPS) and Patient-actuated serial stretch (PASS)

Key Coverage Statements Revised1) Upper-extremity mechanical stretching devices proven and medically necessary in certain circumstances; 2) LLPS as adjuncts proven and medically necessary for treating existing joint contractures of the upper and lower extremities (when not addressed in InterQual); 3) SPS splint devices unproven and not medically necessary for upper and lower extremities

Policy scopeKansas only

Effective dateAugust 1, 2025

Policy numberCSO77KS.02

Medical Necessity Criteria

Medically Necessary - Mechanical stretching devices of the upper extremities

Covered when ALL of the following are met:

ALL of the following

Policy applies only to the state of Kansas
Scope limitation
For medical necessity clinical coverage criteria, refer to the InterQual CP: Durable Medical Equipment; Stretching Devices, Upper Extremity
InterQual reference

(See InterQual criteria for detailed medical necessity requirements and device-specific clinical criteria)

Refer to InterQual for medical necessity clinical coverage criteria

Medically Necessary - Low-load prolonged-duration stretch devices (LLPS)

Coverage Rationale (Revision Summary)

Revision summary (coverage rationale): The policy revision (has material change = true) replaces prior language to clarify that mechanical stretching devices of the upper extremities are proven and medically necessary in certain circumstances and expands the LLPS statement to specify that LLPS devices, when used as an adjunct to therapy and not addressed in InterQual criteria, are proven and medically necessary for treating existing joint contractures of the upper and lower extremities. The revision also clarifies that SPS devices are unproven and not medically necessary (alone or combined with standard PT) for treating joint contractures of the upper and lower extremities. The policy now directs providers to the InterQual CP: Durable Medical Equipment; Stretching Devices, Upper Extremity for medical necessity clinical coverage criteria where applicable.

Coding

Referenced HCPCS / DME CodesHCPCS

E1399	Durable medical equipment, miscellaneous
E1800
E1801	Static progressive stretch/patient actuated serial 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
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 and flexion 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

1–10 of 30

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Provider Actions & Billing Guidance

Documentation Required

Refer to InterQual criteria for medical necessity

For medical necessity clinical coverage criteria for mechanical stretching devices of the upper extremities, providers must refer to the InterQual CP: Durable Medical Equipment; Stretching Devices, Upper Extremity.

Billing Rule

Code use guidance

Listed HCPCS codes are provided for reference and do not guarantee coverage or reimbursement. Benefit coverage for health services is determined by federal, state, or contractual requirements and applicable laws.

E1399
E1800-E1841
Coverage determined by federal, state, or contractual requirements and applicable laws

Background & Evidence

Background: Mechanical stretching devices (also termed dynamic splinting systems) are used to prevent and treat joint contractures by maintaining or restoring range of motion (ROM). The major device types described are Low-load prolonged-duration stretch (LLPS) devices (dynamic splinting designed to provide prolonged low-load stretch, often used during rest or sleep), Static progressive stretch (SPS) devices (splints that hold a joint at a set position with manual angle modification and do not provide continuous stress for motion), and Patient-actuated serial stretch (PASS) devices (patient-controlled mechanical stretching that applies varying loads). Devices may be prefabricated (for common joints such as elbow, wrist, fingers, knee, ankle, toes) or custom when prefabricated units are not suitable due to limb size/shape or load/material requirements. The FDA classifies these devices as Class I, 510(k) exempt, product code ION.

Source	Summary
Hayes Technology Assessment	Concludes evidence insufficient to draw conclusions about efficacy of SPS, PASS, or LLPS for most indications (2018, updated 2022); notes some LLPS benefit for finger extensor injury
Systematic reviews / RCTs cited	Multiple RCTs and systematic reviews of mixed quality: LLPS shows some short-term ROM gains in randomized trials but often no long-term functional benefit; overall evidence quality fair-to-low with methodological limitations
Hayes, Inc. Medical Technology Directory	Entry: 'Mechanical Stretching Devices for the Treatment of Joint Contractures of the Extremities' (updated 9/2022) summarizing evidence and device use
Cochrane Review	Harvey et al. 2017 systematic review: found stretch interventions (including splinting) do not demonstrate clear effectiveness for treatment/prevention of contractures and effects on joint mobility were not supported
Hayes Technology Assessment (policy note)	Hayes report cited in policy states evidence insufficient to support SPS, PASS, or LLPS for many indications except limited evidence for finger extensor injury (policy references Hayes 2018, updated 2022)

Definitions

LLPSLow-load prolonged-duration stretch devices; dynamic splinting systems designed to provide prolonged low-load stretch (used during rest/sleep)

SPSStatic progressive stretch devices; splints that hold the joint in a set position and allow manual angle modification, do not exert continuous stress for motion

PASSPatient-actuated serial stretch devices; patient-controlled mechanical stretching applying varying loads

Revision History

revisionLatest

Clarified that LLPS devices as adjuncts not addressed in InterQual are proven and medically necessary for treating existing joint contractures of the upper and lower extremities; clarified SPS devices are unproven and not medically necessary for upper and lower extremities. Replaced prior language to clarify mechanical stretching devices of the upper extremities are proven and medically necessary in certain circumstances.

revision

Removed reference to InterQual CP: Durable Medical Equipment; Orthoses, Upper Extremity and added reference to the InterQual CP: Durable Medical Equipment; Stretching Devices, Upper Extremity.