UnitedHealthcare mechanical stretching devices Coverage Update

Coverage Criteria

LLPS (covered)

Covered when ALL of the following are met

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

Refer to InterQual CP: Durable Medical Equipment, Stretching Devices, Upper Extremity for specific upper-extremity clinical coverage criteria.

PASS and SPS (not medically necessary)

Not covered / Not medically necessary

Unproven device types: Patient-actuated serial stretch (PASS) devices and static progressive stretch (SPS) splint devices are unproven and not medically necessary for treating joint contractures of the upper and lower extremities due to insufficient evidence of efficacy.

This applies when used alone or combined with standard physical therapy.

There is insufficient evidence to support the routine use of dynamic low‑load prolonged‑duration stretch (LLPS) devices for chronic joint stiffness or fixed contractures resulting from chronic medical conditions (for example, rheumatoid arthritis, cerebral palsy, or plantar fasciitis). Although randomized trials and observational studies support LLPS for certain post‑injury or post‑surgical contractures at specific anatomic sites, the published literature provides minimal evidence of effectiveness for joints other than the finger, wrist, elbow, knee, and toe.

Clinical evidence is not sufficient to demonstrate that static progressive stretch (SPS) or patient‑actuated serial stretch (PASS) devices are effective treatment options for joint contractures. Systematic reviews and observational studies report heterogeneity, small sample sizes, and short follow‑up, and a Hayes technology report concluded that evidence is insufficient to draw conclusions about SPS, PASS, or LLPS for most joint contracture indications.

Patient‑actuated serial stretch (PASS) devices and static progressive stretch (SPS) splint devices are listed as unproven and not medically necessary for treating joint contractures of the upper and lower extremities due to insufficient evidence of efficacy, whether used alone or combined with standard physical therapy.

Available clinical studies do not provide robust, consistent evidence to support SPS or PASS devices as effective treatments for joint contractures. Reviews and primary studies highlight methodological limitations and inadequate trial data; therefore the body of evidence is insufficient to conclude that SPS or PASS improve clinically meaningful outcomes.

Coding

Applicable HCPCS CodesHCPCS

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

Anatomic sites with supportive evidence

Supported anatomic sitesFinger, wrist, elbow, knee, and toe (limited evidence supports LLPS effectiveness for these joints)

Unsupported/limited sitesJoints beyond finger, wrist, elbow, knee, and toe have minimal evidence for LLPS effectiveness

Clinical limitationInsufficient evidence to support use of dynamic LLPS devices for chronic fixed contractures from chronic conditions (e.g., rheumatoid arthritis, cerebral palsy, plantar fasciitis)

Provider Actions & Authorization

Note

Verify Benefit & Criteria Sources

Verify benefit and criteria sources before requesting coverage. Benefit coverage for health services is determined by federal, state (Ohio Administrative Code [OAC]), or contractual requirements, and applicable laws that may require coverage for a specific service. In the event of a conflict, those requirements govern. UnitedHealthcare uses InterQual® for primary medical/surgical criteria for durable medical equipment (including upper-extremity stretching devices). If InterQual® does not have applicable criteria, UnitedHealthcare may use its Medical Policies, Coverage Determination Guidelines, and/or Utilization Review Guidelines. Checking plan-specific benefit documents and any applicable federal or state mandates is required prior to authorization submission.

Confirm member’s specific benefit plan, federal/state/contractual mandates, and any OAC requirements that may affect coverage
Reference InterQual® CP: Durable Medical Equipment, Stretching Devices, Upper Extremity for clinical criteria
If InterQual® criteria do not apply, reference UnitedHealthcare Medical Policies/Coverage Determination Guidelines as applicable

Documentation Required

Medical Record Requirements

Medical Necessity Determinations

DME medical necessity — InterQual for upper-extremity devices; LLPS devices supported for existing joint contractures

Medical necessity determined per InterQual for upper-extremity devices; LLPS devices supported for existing joint contractures.

General necessity: Device intended to prevent or treat joint contracture with the goal to maintain or restore range of motion; documentation must show contracture attributable to immobilization, surgery, disease, or trauma and provide clinical rationale for device use versus alternative therapies.

InterQual CP referenced for specific upper-extremity criteria; LLPS may be used in home or hospital settings as adjunct to therapy.

Evidence summaries — clinical evidence summaries that may inform necessity determinations

Clinical evidence summaries that may inform necessity determinations include:

LLPS evidence: Systematic review (Furia et al. 2013) of dynamic/LLPS devices found 8 studies (487 subjects) with a mean aggregate improvement in active range of motion (AROM) of 23.5° and a direct linear correlation between total hours of stretching and restored AROM; multiple controlled and randomized studies report short-term ROM improvements and reduced surgical rates in selected indications (adhesive capsulitis, carpal tunnel, knee/hand tendon rehabilitation).

Rental and Purchase Rules

HCPCS code	Description	Coverage status / Rental vs Purchase
E1399
Durable medical equipment, miscellaneous.
neutral — Policy lists as applicable DME supply code; rental vs purchase instructions not specified in policy.
E1800
Dynamic adjustable elbow extension and flexion device, includes soft interface material.
neutral — Policy lists as applicable DME supply code; rental vs purchase instructions not specified in policy.
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.
neutral — Code listed; device type (SPS/PASS) is considered unproven and not medically necessary per policy.
E1802
Dynamic adjustable forearm pronation/supination device, includes soft interface material.
neutral — Policy lists as applicable DME supply code; rental vs purchase instructions not specified in policy.
E1803
Dynamic adjustable elbow extension only device, includes soft interface material.
neutral — Policy lists as applicable DME supply code; rental vs purchase instructions not specified in policy.
E1804
Dynamic adjustable elbow flexion only device, includes soft interface material.
neutral — Policy lists as applicable DME supply code; rental vs purchase instructions not specified in policy.
E1805
Dynamic adjustable wrist extension and flexion device, includes soft interface material.
neutral — Policy lists as applicable DME supply code; rental vs purchase instructions not specified in policy.
E1806
Static progressive stretch wrist device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories.
neutral — Code listed; device type (SPS) is considered unproven and not medically necessary per policy.
E1807
Dynamic adjustable wrist extension only device, includes soft interface material.
neutral — Policy lists as applicable DME supply code; rental vs purchase instructions not specified in policy.
E1808
Dynamic adjustable wrist flexion only device, includes soft interface material.
neutral — Policy lists as applicable DME supply code; rental vs purchase instructions not specified in policy.
E1810
Dynamic adjustable knee extension and flexion device, includes soft interface material.
neutral — Policy lists as applicable DME supply code; rental vs purchase instructions not specified in policy.
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.
neutral — Code listed; device type (SPS/PASS) is considered unproven and not medically necessary per policy.
E1812
Dynamic knee, extension/flexion device with active resistance control.
neutral — Policy lists as applicable DME supply code; rental vs purchase instructions not specified in policy.
E1813
Dynamic adjustable knee extension only device, includes soft interface material.
neutral — Policy lists as applicable DME supply code; rental vs purchase instructions not specified in policy.
E1814
Dynamic adjustable knee flexion only device, includes soft interface material.
neutral — Policy lists as applicable DME supply code; rental vs purchase instructions not specified in policy.
E1815
Dynamic adjustable ankle extension and flexion device, includes soft interface material.
neutral — Policy lists as applicable DME supply code; rental vs purchase instructions not specified in policy.
E1816
Static progressive stretch/patient actualized serial stretch ankle device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories.
neutral — Code listed; device type (SPS/PASS) is considered unproven and not medically necessary per policy.
E1818
Static progressive stretch/patient actualized serial stretch forearm pronation/supination device, with or without range of motion adjustment, includes all components and accessories.
neutral — Code listed; device type (SPS/PASS) is considered unproven and not medically necessary per policy.
E1822
Dynamic adjustable ankle extension only device, includes soft interface material.
neutral — Policy lists as applicable DME supply code; rental vs purchase instructions not specified in policy.
E1823
Dynamic adjustable ankle flexion only device, includes soft interface material.
neutral — Policy lists as applicable DME supply code; rental vs purchase instructions not specified in policy.
E1825
Dynamic adjustable finger extension and flexion device, includes soft interface material.
neutral — Policy lists as applicable DME supply code; LLPS (dynamic) devices are considered medically necessary when criteria met; rental vs purchase instructions not specified in policy.
E1826
Dynamic adjustable finger extension only device, includes soft interface material.
neutral — Policy lists as applicable DME supply code; LLPS (dynamic) devices are considered medically necessary when criteria met; rental vs purchase instructions not specified in policy.
E1827
Dynamic adjustable finger flexion only device, includes soft interface material.
neutral — Policy lists as applicable DME supply code; LLPS (dynamic) devices are considered medically necessary when criteria met; rental vs purchase instructions not specified in policy.
E1828
Dynamic adjustable toe extension only device, includes soft interface material.
neutral — Policy lists as applicable DME supply code; LLPS (dynamic) devices are considered medically necessary when criteria met; rental vs purchase instructions not specified in policy.
E1829
Dynamic adjustable toe flexion only device, includes soft interface material.
neutral — Policy lists as applicable DME supply code; LLPS (dynamic) devices are considered medically necessary when criteria met; rental vs purchase instructions not specified in policy.
E1830
Dynamic adjustable toe extension and flexion device, includes soft interface material.
neutral — Policy lists as applicable DME supply code; LLPS (dynamic) devices are considered medically necessary when criteria met; rental vs purchase instructions not specified in policy.
E1831
Static progressive stretch toe device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories.
neutral — Code listed; device type (SPS) is considered unproven and not medically necessary per policy.
E1832
Static progressive stretch finger device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories.
neutral — Code listed; device type (SPS) is considered unproven and not medically necessary per policy.
E1840
Dynamic adjustable shoulder flexion/abduction/rotation device, includes soft interface material.
neutral — Policy lists as applicable DME supply code; rental vs purchase instructions not specified in policy.
E1841
Static progressive stretch/patient actualized serial stretch shoulder device, with or without range of motion adjustment, includes all components and accessories.
neutral — Code listed; device type (SPS/PASS) is considered unproven and not medically necessary per policy.

Documentation Requirements

Documentation Required

Maintain legible records; make available on request

Maintain legible medical records that document the clinical rationale and must be made available upon request.

Records should include relevant history, physical exam findings, and diagnostic test results that support medical necessity.

Documentation Required

Provide records when requested for coverage review

Provide documentation upon request to support that the member meets clinical criteria; availability of records may be required to complete coverage review.

Absence of supporting documentation may result in denial of coverage.

Documentation Required

Document history, exam, and test results in the chart

Ensure the patient's medical record contains legible documentation of relevant history, physical examination, and results of pertinent diagnostic tests or procedures and make it available upon request.

Definitions

Device type definitions

LLPS (Low-Load Prolonged-Duration Stretch)Adjustable spring-loaded/dynamic splinting systems that provide prolonged low-load passive stretch (often used during rest or sleep) for restoration of joint ROM; available for elbow, wrist, fingers, knee, ankle, and toes

SPS (Static Progressive Stretch)Splints that hold the joint in a set position and allow manual modification of joint angle (inelastic traction); do not exert dynamic stress or allow active/passive motion

PASS (Patient-Actuated Serial Stretch)Devices using pneumatic or hydraulic systems that deliver adjustable low- to high-level loads allowing the patient to control incremental stretches; protocols include customized treatment plans and patient education

LLPS examples (Dynasplint, Ultraflex)

ExamplesDynasplint and Ultraflex dynamic splinting systems are examples of LLPS devices delivering prolonged passive stretching

Background

A joint contracture is a reduction in range of motion caused by structural changes in periarticular soft tissues following immobilization, surgery, disease, or trauma. Mechanical stretching devices are intended to prevent or treat contractures by providing controlled, repeated stretching to maintain or restore motion; they may be used in hospital settings or as home therapy adjuncts to formal rehabilitation programs.

Not Covered / Exclusions

Patient‑actuated serial stretch (PASS) devices and static progressive stretch (SPS) splint devices are considered unproven and not medically necessary for joint contractures. Evidence supporting LLPS is limited to specific anatomic sites (finger, wrist, elbow, knee, and toe), and there is minimal evidence for use of these devices at other joints or for chronic fixed contractures from chronic conditions.

A Hayes technology report concludes that the evidence is insufficient to support the use of PASS devices for any indication and that, for SPS, PASS, and LLPS devices there are too few studies across most joint contracture applications to draw conclusions about efficacy (exception noted only for a limited application such as finger extensor injury). As a result, PASS devices are not supported by sufficient evidence to demonstrate safety and effectiveness for any indication.

OpenPayer

Mechanical Stretching Devices (for Ohio Only)

Coverage Criteria

Coding

Provider Actions & Authorization

Medical Necessity Determinations

Rental and Purchase Rules

Documentation Requirements

Definitions

Background

Not Covered / Exclusions