ModifiedUnitedHealthcarePolicy CS077ID.C

Mechanical Stretching Devices (for Idaho Only)

Defines UnitedHealthcare coverage and evidence-based stance on mechanical stretching devices (LLPS, SPS, PASS) for treatment of joint contractures in Idaho members, including Idaho Medicaid Plus.

Policy Summary

PayerUnitedHealthcare

PolicyMechanical Stretching Devices (for Idaho Only)

Policy CodePolicy CS077ID.C

Change TypeDocumentation clarifications (added/clarified/removed items)

Effective DateApr 1, 2026

Next Review Date

Key ActionProvide complete, legible medical record documentation (history, exam, diagnostic tests) to demonstrate medical necessity for prior authorization and review.

SourceLink

POLICY UPDATE CHANGES

The patient's medical record must contain documentation that fully supports the medical necessity for the requested services.

Removed reference link to the guidelines titled Medical Records Documentation Used for Reviews.

Added examples of documentation that support medical necessity (relevant medical history, physical examination, and pertinent diagnostic tests/procedures).

Idaho-onlystate applicability

CoveredLLPS coverage

Not medically necessarySPS & PASS stance

Multiple E-codes

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Coverage Criteria for Mechanical Stretching Devices

LLPS - Medically necessary

Covered when ALL of the following are met

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

Applies when LLPS is provided as an adjunct to therapy for persistent joint stiffness after injury or surgery; limited evidence for some joints (minimal evidence for joints beyond finger, wrist, elbow, knee, and toe).

SPS and PASS - Not medically necessary / unproven

Not medically necessary when ANY of the following apply

SPS exclusion: Static progressive stretch (SPS) splint devices are unproven and not medically necessary for treating joint contractures of the upper and lower extremities.

SPS is not supported by sufficient clinical evidence to demonstrate effectiveness for treating joint contractures.

PASS exclusion: Patient-actuated serial stretch (PASS) devices are unproven and not medically necessary for treating joint contractures of the upper and lower extremities.

PASS devices (pneumatic or hydraulic, patient-controlled) lack sufficient evidence of safety, efficacy, and long-term outcomes for any indication.

Evidence-based coverage conclusions by device type

Coverage conclusions summarized from clinical evidence in the policy:

LLPS: Evidence from randomized and controlled studies (for example, Khandwala et al. 2000) suggests LLPS used with active mobilization may have similar efficacy and safety to static splinting plus active mobilization for extensor tendon repairs in the hand (zones 5-6).

Supports coverage for LLPS as an adjunct to therapy for specified indications; evidence for other joints is limited.

SPS: Clinical evidence for static progressive stretch devices is mixed and overall insufficient to definitively demonstrate effectiveness across indications; some small trials and observational studies report benefit in specific contexts, but systematic reviews do not show clear superiority of stretch interventions overall.

May be considered investigational or not medically necessary depending on indication.

PASS: Evidence is insufficient to demonstrate safety, efficacy, or long-term outcomes for PASS devices for any indication; well-designed clinical trials are lacking.

Supports a non-coverage or investigational stance for general use of PASS devices.

Clinical evidence is insufficient to demonstrate that static progressive stretch (SPS) devices are an effective treatment option for joint contractures. The policy explicitly states SPS splint devices are unproven and not medically necessary for treating joint contractures of the upper and lower extremities due to lack of adequate evidence of efficacy across indications (including finger, wrist, elbow, knee, shoulder, and toe applications).

Systematic reviews and controlled trials report mixed results and generally do not show clear superiority of SPS-based splinting over other stretch interventions or standard care; limitations across studies include small sample sizes, short follow-up, and heterogeneity of interventions and populations, which preclude firm conclusions about clinical benefit.

Available published evidence is insufficient to support the safety, efficacy, or long-term outcomes of patient-actuated serial stretch (PASS) devices for any indication. The policy finds that well-designed clinical trials evaluating PASS devices are lacking, preventing determination of whether these devices, alone or adjunctive to physical therapy, improve patient outcomes.

Because the body of literature does not establish consistent benefit or safety data for PASS devices, their use for treating joint contractures is considered investigational and not supported for coverage in routine practice.

Static progressive stretch (SPS) and patient-actuated serial stretch (PASS) devices are considered unproven and not medically necessary for treating joint contractures of the upper and lower extremities. The policy groups both device types as noncovered when used alone or combined with standard physical therapy because the clinical evidence does not demonstrate consistent effectiveness.

Requests for SPS or PASS devices for joint contractures therefore carry a high risk of denial absent compelling, indication-specific evidence documented in the medical record.

Systematic reviews and observational studies assessing stretch interventions, including device-administered splinting, report that stretch therapies in general do not demonstrate clear, consistent effectiveness for prevention or treatment of contractures across neurological and non-neurological populations. Meta-analytic data found no meaningful improvement in joint mobility with splinting compared with control (mean difference ~0° in pooled analyses).

Some small observational studies and select controlled trials of static progressive stretch report improvements in range of motion in specific cohorts (for example, small post-TKA or hemophilia series), but these studies have methodological limitations (very small sample sizes, lack of controls, short follow-up) that limit generalizability. Overall, the evidence does not support routine use of device-administered splinting as a proven intervention for contracture management.

Coding and HCPCS References

Referenced HCPCS E-codes (part 1)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.

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Referenced HCPCS E-codes (part 2)HCPCS

E1822	Dynamic adjustable ankle extension only device, includes soft interface material.
E1823	Dynamic adjustable ankle flexion only device, includes soft interface material.
E1825	Dynamic adjustable finger extension and flexion device, includes soft interface material.
E1826	Dynamic adjustable finger extension only device, includes soft interface material.
E1827	Dynamic adjustable finger flexion only device, includes soft interface material.
E1828	Dynamic adjustable toe extension only device, includes soft interface material.
E1829	Dynamic adjustable toe flexion only device, includes soft interface material.
E1830	Dynamic adjustable toe extension and flexion device, includes soft interface material.
E1831	Static progressive stretch toe device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories.
E1832	Static progressive stretch finger device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories.

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Provider Actions, Authorization, and Documentation

Prior Authorization

Prior Authorization and Referenced HCPCS Codes

Prior authorization requirements apply per member contract and state/federal rules. Listed HCPCS E-codes are referenced for devices; prior authorization may be required for durable medical equipment requests. Providers should verify benefit coverage and obtain any required authorizations before device procurement or billing.

Prior authorization applies when required by the member's contract or state/federal law
Referenced HCPCS: E1399, E1800–E1841 (see Applicable Codes section)

Documentation Required

Required Medical Record Documentation

The patient's medical record must contain documentation that fully supports the medical necessity for the requested services. This includes, but is not limited to, relevant history, physical examination findings, and results of pertinent diagnostic tests or procedures. Documentation must be legible, maintained in the patient's medical record, and made available upon request.

Background and Evidence Summary

Joint contracture is a reduction in range of motion resulting from structural changes in non-bony tissues (muscle, tendon, fascia, skin, or joint capsule) that may follow surgery, disease, trauma, or prolonged immobilization. Mechanical stretching devices are intended to maintain or restore joint range of motion by delivering controlled, repeated stretch, potentially reducing the need for therapist-directed sessions by providing frequent home- or hospital-based mobilization.

Device Definitions

inv-19: Low-load prolonged-duration stretch (LLPS) — Dynamic splinting systems description

DefinitionDynamic splinting systems that provide prolonged low-load stretch (LLPS) using adjustable spring-loaded mechanisms to restore joint range of motion; available prefabricated or custom for elbow, wrist, fingers, knee, ankle, and toes.

Typical mechanismAdjustable spring-loaded (dynamic) components deliver low-load prolonged-duration stretch while the individual is asleep or at rest.

Indications in policyUsed as an adjunct to therapy to treat existing joint contractures of the upper and lower extremities when conservative treatment is indicated.

CustomizationCustom dynamic splints may be used when prefabricated units cannot provide effective treatment due to limb size/shape or load/material requirements.

Clinical evidence noteAn RCT (Khandwala et al. 2000) demonstrated similar efficacy and safety of LLPS plus active mobilization versus static splinting plus active mobilization for hand extensor tendon repairs.

Policy Summary

PayerUnitedHealthcare

PolicyMechanical Stretching Devices (for Idaho Only)

Policy CodePolicy CS077ID.C

Change TypeDocumentation clarifications (added/clarified/removed items)

Effective DateApr 1, 2026

Next Review Date

Key ActionProvide complete, legible medical record documentation (history, exam, diagnostic tests) to demonstrate medical necessity for prior authorization and review.

SourceLink

On This Page

Document relevant history and prior treatments

Include focused physical exam findings demonstrating contracture and functional limitation

Attach pertinent diagnostic test results or objective measures of range of motion

Denial Risk

Documentation-Linked Denial Risk

Lack of adequate medical record documentation supporting the medical necessity for the requested device or service may result in denial of the request. Ensure records clearly link the requested device to the member's diagnosis, prior conservative therapies, objective findings, and functional impairment.

Denial risk if documentation does not demonstrate medical necessity
Include timeline of conservative therapy attempts and responses to support escalation
Make records available for prior authorization review

Step Therapy

Conservative Therapy Before Escalation

Conservative therapy should be documented and attempted prior to escalation to mechanical stretch devices when clinically appropriate. Multimodal physical therapy (manual therapy, therapeutic exercise, and other PT modalities) with documented adherence and response is supported by some evidence and should be considered before requesting SPS or PASS devices.

Document course and duration of physical therapy, including specific modalities and patient adherence
Include objective measures of ROM before and after conservative therapy
If conservative therapy failed or was not feasible, document reasons (e.g., intolerance, surgical contraindication, or insufficient progress)

Denial Risk

Denial Risk for SPS and PASS Devices

Requests for SPS or PASS devices to treat joint contractures are considered not medically necessary per the Coverage Rationale and may be denied. LLPS (dynamic splinting) devices are the proven adjunct to therapy; SPS and PASS devices lack sufficient evidence of efficacy for coverage.

SPS devices (static progressive stretch) — considered not medically necessary
PASS devices (patient-actuated serial stretch) — considered not medically necessary

inv-20: Static progressive stretch (SPS) — Splint devices held in set position with manual modification description

DefinitionStatic progressive stretch (SPS) devices hold the joint in a set position and allow manual modification of the joint angle (inelastic traction); they do not permit active or passive motion while held.

MechanismDevice angle is manually adjusted to increase stretch in a stepwise manner (static progressive loading) rather than providing continuous dynamic load.

Clinical evidence summaryPolicy states clinical evidence is insufficient to demonstrate SPS devices are an effective treatment option for joint contractures; systematic reviews report mixed results.

Examples of useUsed as an adjunct to physical therapy in studies for conditions such as adhesive capsulitis, post-TKA rehabilitation, and elbow stiffness, but evidence is limited and inconsistent.

inv-21: Patient-actuated serial stretch (PASS) — Devices providing adjustable load using pneumatic or hydraulic systems

DefinitionPatient-actuated serial stretch (PASS) devices use pneumatic or hydraulic systems to provide adjustable load that the individual controls to vary stretch intensity.

MechanismLoad delivered via pneumatic (e.g., Extensionaters) or hydraulic (e.g., Flexionaters) components allowing patient-adjusted low- to high-level loading.

Policy evidence statementClinical evidence is insufficient to demonstrate PASS devices are effective for treating joint contractures; well-designed trials are lacking.

Application noteDifferent PASS devices are available for knee/ankle, knee, and shoulder; protocols typically include a customized treatment plan and patient education.

inv-22: LLPS — Low-Load Prolonged-Duration Stretch (abbrev entry)

AbbreviationLLPS = Low-Load Prolonged-Duration Stretch

SynonymDynamic splinting

Typical jointsElbow, wrist, fingers, knee, ankle, toes

inv-23: SPS — Static Progressive Stretch (abbrev entry)

AbbreviationSPS = Static Progressive Stretch

Also described asStatic splinting with manual angle modification (inelastic traction)

Policy stanceSPS devices are considered unproven/insufficient evidence for general treatment of joint contractures per the policy.

inv-24: PASS — Patient-Actuated Serial Stretch (abbrev entry)

AbbreviationPASS = Patient-Actuated Serial Stretch

Mechanism summaryPatient-adjustable pneumatic or hydraulic load to provide serial stretch increments.

Policy stancePASS devices lack sufficient evidence for safety and efficacy and are considered unproven/not medically necessary in this policy.