Mechanical Stretching Devices (for Louisiana Only)

Coverage Summary

This policy applies only to the state of Louisiana and is effective June 1, 2025. It addresses coverage for mechanical stretching devices (dynamic splinting systems) used to prevent or treat joint contractures of the upper and lower extremities and includes literature references and policy revision/coding history.

The policy takes a mixed coverage stance by device type: Low‑load prolonged‑duration stretch (LLPS) devices used as an adjunct to therapy are considered proven and medically necessary for treating existing joint contractures of the upper and lower extremities, whereas Static progressive stretch (SPS) devices and Patient‑actuated serial stretch (PASS) devices are considered unproven and not medically necessary due to insufficient evidence of efficacy.

This part contains cited literature (systematic reviews, randomized trials, Hayes reports, and other references) and policy history/coding updates (including the addition of HCPCS code E1832 and revised descriptions for codes E1801, E1811, E1816, E1818, and E1841), which are presented in the supporting information and revision history.

Policy metadata

Effective DateJune 1, 2025

StatusCURRENT

ScopeLouisiana-only UnitedHealthcare Community Plan medical policy for mechanical stretching devices addressing coverage rationale, evidence, and applicable HCPCS/DME codes for LLPS, SPS, PASS

States Applicable1

Number of HCPCS codes listed22

Literature references cited~30

Medical Necessity and Unproven Criteria

Medically Necessary

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:

Medically Necessary - LLPS

Device is a low-load prolonged-duration stretch (LLPS) device used as an adjunct to therapy
Indication is treatment of existing joint contracture of the upper or lower extremities

Not Medically Necessary / Unproven

The following are unproven and not medically necessary, alone or combined with standard physical therapy (PT), for treating joint contractures of the upper and lower extremities due to insufficient evidence of efficacy:

HCPCS / DME Codes

Applicable HCPCS / DME codes (listed for reference)HCPCS

E1399	Durable medical equipment; miscellaneous.
E1800	Dynamic adjustable elbow extension and flexion device, includes soft interface material.
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

1/3

Codes not on Louisiana Medicaid Fee Schedule (therefore not covered by State of Louisiana Medicaid)HCPCSNot Covered

E1801	Static progressive stretch/patient actuated serial stretch elbow device
E1806	Static progressive stretch wrist device
E1811	Static progressive stretch/patient actuated serial stretch knee device
E1816	Static progressive stretch ankle device
E1818	Static progressive stretch/patient actuated serial stretch forearm pronation/supination device
E1831	Static progressive stretch toe device
E1841	Static progressive stretch/patient actuated serial stretch shoulder device

Applicable HCPCS codes updated (per revision history)HCPCS

E1832	Added (no description text provided in this part)
E1801	Description revised (exact revised description not provided in this part)
E1811	Description revised (exact revised description not provided in this part)
E1816	Description revised (exact revised description not provided in this part)
E1818	Description revised (exact revised description not provided in this part)
E1841	Description revised (exact revised description not provided in this part)

Provider Actions / Billing Guidance

Documentation Required

State-specific applicability

This policy applies only to members in the state of Louisiana. Providers must follow Louisiana-specific coverage rules and verify whether listed HCPCS codes are included on the Louisiana Medicaid fee schedule before billing or seeking reimbursement.

Note: Codes marked with an asterisk in the Applicable Codes list are not on the State of Louisiana Medicaid Fee Schedule and therefore are not covered by the State of Louisiana Medicaid Program.

Billing Rule

Reference-only codes and coverage determination

The policy lists HCPCS codes for reference only; inclusion does not guarantee coverage or reimbursement. Coverage and payment are determined by applicable federal, state, or contractual requirements and laws.

Referenced HCPCS codes: E1399, E1800, E1801, E1802, E1803, E1804, E1805, E1806, E1807, E1808, E1810, E1811, E1812, E1813, E1814, E1815, E1816, E1818, E1822, E1823, E1825, E1826, E1827, E1828, E1829, E1830, E1831, E1832, E1840, E1841.

Background and 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 (ROM). The devices described in this policy include three types: Low‑load prolonged‑duration stretch (LLPS) devices (dynamic splinting delivering prolonged, low load), Static progressive stretch (SPS) splinting devices (hold the joint in a set position with manual angle adjustment and do not permit active/passive motion), and Patient‑actuated serial stretch (PASS) devices (patient‑controlled mechanical stretching, often pneumatic).

LLPS/dynamic splinting systems are adjustable, spring‑loaded devices available as prefabricated or custom units for multiple joints (finger, wrist, elbow, knee, ankle, toe, shoulder) and are intended to provide frequent, consistent mobilization in clinic or home settings. SPS devices apply inelastic traction by positioning the joint and allowing manual progressive adjustments, while PASS devices apply variable loads under patient control per device‑specific protocols.

The quality of evidence varies by device type and indication: randomized trials, observational studies, and systematic reviews provide fair‑to‑low quality evidence supporting LLPS for certain contractures and show some short‑term ROM benefits in selected indications, whereas the published evidence for SPS and PASS devices is insufficient to demonstrate effectiveness or long‑term outcomes.

Source	Summary
Hayes report	Hayes (Medical Technology Directory, 2018 updated 2022): Evidence insufficient for SPS and PASS; LLPS evidence fair-to-low with limited clinical benefit beyond ROM for some indications
Systematic reviews/RCTs	Mixed evidence from systematic reviews and randomized trials: some small short-term ROM gains with LLPS, many studies limited by small sample sizes, heterogeneity, short follow-up, and methodological limitations
Cochrane review	Harvey LA et al., Cochrane Database Syst Rev 2017 (Stretch for contractures): review of 49 studies found no clear benefit of stretch interventions overall and concluded effects of stretch are uncertain
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Definitions

LLPS (Low-load prolonged-duration stretch)Dynamic splinting systems providing low-load prolonged-duration stretch to restore joint range of motion (used as adjunct to therapy)

Revision History

2025-06-01code_addedLatest

Added HCPCS code E1832 to the list of applicable codes (Static progressive stretch finger device, extension and/or flexion; includes all components and accessories).

2025-06-01descriptions_revisedLatest

Revised descriptions for HCPCS codes E1801, E1811, E1816, E1818, and E1841 per quarterly HCPCS edits; exact revised descriptions not provided in this part.

2025-06-01policy_archived