CurrentUnitedHealthcarePolicy CS077NJ.P

Mechanical Stretching Devices Nj Cs

State-specific UnitedHealthcare medical policy for mechanical stretching devices in New Jersey describing coverage rationale, clinical evidence, applicable HCPCS codes, and documentation requirements for low-load prolonged-duration stretch (LLPS), static progressive stretch (SPS), and patient-actuated serial stretch (PASS) devices.

Policy Summary

PayerUnitedHealthcare

PolicyMechanical Stretching Devices Nj Cs

Policy CodePolicy CS077NJ.P

Change TypeDocumentation, coding, references

Effective DateDec 1, 2025

Next Review Date

Key ActionPatient medical records must document medical necessity including relevant history, physical examination, and pertinent diagnostic test results; documentation must be legible and available upon request.

SourceLink

POLICY UPDATE CHANGES

Added medical records documentation requirements used for reviews.

Added notation that HCPCS code E1832 is not on the NJ Medicaid Fee Schedule and therefore not covered by NJ Medicaid.

Added language clarifying that benefit coverage is determined by federal, state, or contractual requirements and applicable laws.

Updated Clinical Evidence and References sections to reflect current information.

Archived previous policy version CS077NJ.O

LLPSLLPS covered for existing joint contractures

SPSSPS considered not medically necessary

Coverage Summary

Scope: This is a New Jersey–specific UnitedHealthcare medical policy (CS077NJ.P) for mechanical stretching devices addressing coverage rationale, applicable HCPCS codes, and documentation requirements for devices used to prevent or treat joint contractures of the extremities. The policy applies only to the State of New Jersey.

High-level coverage stance: Low-load prolonged-duration stretch (LLPS) devices (dynamic splinting) are covered (medically necessary) as an adjunct to therapy for treating existing joint contractures of the upper and lower extremities to maintain or restore range of motion. Static progressive stretch (SPS) devices and patient-actuated serial stretch (PASS) devices are considered unproven and not medically necessary due to insufficient evidence. Providers should note the listed HCPCS codes in the policy; codes marked with an asterisk are not on the New Jersey Medicaid Fee Schedule and therefore may not be covered by NJ Medicaid. Specifically, HCPCS code E1832 is noted as not payable under the State of New Jersey Medicaid Fee Schedule.

Key Policy Facts

policy_numberCS077NJ.P

effective_date2025-12-01

jurisdictionNew Jersey

coverage_stance_summaryMixed: LLPS (low-load prolonged-duration stretch) devices covered as adjunct to therapy for existing joint contractures; SPS (static progressive stretch) and PASS (patient-actuated serial stretch) devices considered unproven and not medically necessary

quick_reference_noteHCPCS codes marked with * are not on the NJ Medicaid Fee Schedule and may not be covered; specifically, HCPCS E1832 is not on the NJ Medicaid Fee Schedule and is not covered by NJ Medicaid

Medical Necessity & Limitations

Medically Necessary (LLPS devices)

Covered when ALL of the following are met:

Device is a low-load prolonged-duration stretch (LLPS) device used as an adjunct to therapy
Treatment is for existing joint contractures of the upper or lower extremities
Used to maintain or restore range of motion (ROM) where dynamic splinting is clinically appropriate

ref": "b1_0

title": "Medically Necessary (LLPS devices)"}

Not Medically Necessary / Unproven Devices

Not Medically Necessary / Unproven

The following are unproven and not medically necessary, alone or combined with standard physical therapy (PT), due to insufficient evidence:

Static progressive stretch (SPS) splint devices are unproven and not medically necessary
Patient-actuated serial stretch (PASS) devices (patient controlled mechanical stretching) are unproven and not medically necessary
Use of LLPS, SPS, or PASS for conditions lacking sufficient evidence of efficacy (examples listed in policy)

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Documentation & Provider Requirements

Documentation requirements for reviews (policy history change 12/01/2025)

Medical records documentation may be required to assess whether the member meets clinical criteria for coverage:

Benefit coverage for health services is determined by the federal, state, or contractual requirements and applicable laws that may require coverage for a specific service
Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the service requested
The patient's medical record must contain documentation that fully supports the medical necessity for the requested services
Documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures

HCPCS Codes

Applicable HCPCS Codes (reference list)HCPCS

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
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 NJ Medicaid Fee Schedule (may not be covered by NJ Medicaid)HCPCSNot Covered

E1801	Static progressive stretch/patient actualized serial stretch elbow device
E1806	Static progressive stretch wrist device
E1811	Static progressive stretch/patient actualized serial stretch knee device
E1816	Static progressive stretch/patient actualized serial stretch ankle device
E1818	Static progressive stretch/patient actualized serial stretch forearm pronation/supination device
E1831	Static progressive stretch toe device
E1832	Static progressive stretch finger device
E1840	Dynamic adjustable shoulder flexion/abduction/rotation device (asterisked in list)
E1841	Static progressive stretch/patient actualized serial stretch shoulder device (asterisked in list)

Not covered for New Jersey Medicaid (HCPCS noted)HCPCSNot Covered

E1832

Dynamic adjustable extension/flexion splint, mechanical

Background & Evidence Summary

Background: Joint contractures are associated with reduced range of motion (ROM) caused by structural changes in non-bony tissues (muscles, tendons, ligaments, skin). Mechanical stretching devices aim to prevent or treat contractures by providing continuous or progressive stretch to restore or maintain ROM.

Definitions and general use: Mechanical stretching devices include LLPS (low-load prolonged-duration stretch / dynamic splinting), SPS (static progressive stretch), and PASS (patient-actuated serial stretch). Dynamic splinting systems are adjustable spring-loaded devices designed to provide LLPS while individuals are asleep or at rest and are available for multiple joints (finger, wrist, elbow, knee, ankle, toes); SPS devices hold a joint in a set position with manual angle modification; PASS devices use pneumatic or hydraulic systems that the patient controls.

Role of LLPS: LLPS (dynamic splinting) is typically used as a home therapy to supplement physical therapy by providing frequent, prolonged passive stretching outside clinic sessions and may replace some therapist-directed sessions when clinically appropriate.

Evidence Item	Brief summary (policy wording / key findings)
Hayes review (2018, updated 2022)
Hayes: evidence rated fair-to-low; small short-term ROM gains for finger contractures with LLPS; insufficient evidence for other indications; clinical significance uncertain
RCTs & systematic reviews (multiple cited)
Multiple RCTs, systematic reviews, and observational studies show mixed results — some support LLPS (finger, wrist, elbow, knee, toe) with limited/short-term ROM gains; studies limited by small sizes, follow-up, and bias; SPS and PASS evidence insufficient
FDA classification / regulatory status
Devices classified as FDA Class I, product code ION, 510(k) exempt (manufacturers not required to submit premarket safety/effectiveness data)
Teytelbaum et al. (2024) randomized trial
Teytelbaum 2024: RCT of at-home high-intensity stretch (HIS) device vs PT and vs PT+HIS in adhesive capsulitis (n=34) — all groups improved ROM; HIS restored >95% contralateral ROM and showed greater ASES and SST score improvements vs PT alone; study had limitations (COVID follow-up losses, potential unblinding)

Definitions

LLPSLow-load prolonged-duration stretch devices (dynamic splinting systems designed to provide LLPS while at rest)

SPSStatic progressive stretch devices (splinting holding joint in set position with manual modification of angle)

Revision History

2025-12-01addedLatest

Added medical records documentation requirements used for reviews: Benefit coverage determined by federal, state, or contractual requirements and applicable laws; medical records documentation may be required to assess whether the member meets clinical criteria but does not guarantee coverage; patient's medical record must contain documentation fully supporting medical necessity, including relevant history, physical exam, and pertinent diagnostic test results; documentation must be legible and available upon request.

2025-12-01addedLatest

Added notation that HCPCS code E1832 is not on the State of New Jersey Medicaid Fee Schedule and therefore is not covered by the State of New Jersey Medicaid Program (operational billing implication for NJ Medicaid claims).

Policy Summary

PayerUnitedHealthcare

PolicyMechanical Stretching Devices Nj Cs

Policy CodePolicy CS077NJ.P

Change TypeDocumentation, coding, references

Effective DateDec 1, 2025

Next Review Date

SourceLink

On This Page

Limitations / Specific Evidence-based Limitations

Coverage and evidence limitations noted in the policy:

Minimal evidence supporting LLPS effectiveness for joints other than finger, wrist, elbow, knee, and toe
Insufficient evidence to support LLPS for chronic joint stiffness or chronic fixed contractures from conditions such as rheumatoid arthritis (RA), cerebral palsy, or plantar fasciitis
Insufficient evidence for PASS devices for any indication

ref": "b1_1

title": "Limitations / Specific Evidence-based Limitations"}

b1_1

Documentation Required

Medical record documentation required

Patient medical records must document medical necessity including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures to support the requested device; documentation must be legible and available upon request.

Documentation Required

Maintain medical record documentation to support medical necessity

Providers must ensure patient medical records contain relevant history, physical exam, and diagnostic test results that fully support the requested service's medical necessity and make them available upon request.

Prior Authorization

New Jersey applicability / policy scope

Policy applies only to the State of New Jersey; providers should follow New Jersey-specific coverage and fee schedule rules. Codes marked with an asterisk are not on the New Jersey Medicaid Fee Schedule and therefore may not be covered — follow state-specific fee schedule and coverage rules when determining benefits.

Billing Rule

HCPCS E1832 not payable under NJ Medicaid Fee Schedule

HCPCS code E1832 is not on the State of New Jersey Medicaid Fee Schedule and therefore is not covered by the State of New Jersey Medicaid Program.

E1832
Not on State of New Jersey Medicaid Fee Schedule — not covered by NJ Medicaid