UnitedHealthcare Mechanical Stretching Devices Coverage Update

Coverage Criteria

LLPS (Covered with criteria)

Covered when ALL of the following are met

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

Supported by randomized controlled trials, observational studies, systematic reviews and medical community acceptance for finger, wrist, elbow, knee, and toe; limited evidence for other joints or for chronic contractures from systemic conditions.

Adjunct-to-therapy use: LLPS is used as an adjunct to physical therapy to provide frequent, consistent joint mobilization in the home or clinical setting and may replace some therapist-directed sessions when appropriate.

Device design (adjustable spring-loaded dynamic splinting) intended for prolonged low-load stretch during rest or sleep; prefabricated and custom options available.

Evidence limitations: Indication should be limited to joints and conditions with evidence (finger, wrist, elbow, knee, toe); use for other joints or for chronic fixed contractures caused by conditions such as rheumatoid arthritis, cerebral palsy, or plantar fasciitis is not supported by sufficient evidence.

Policy supports LLPS for documented contractures in the indicated joints based on available trials and reviews; extrapolation to other joints/conditions is not supported.

SPS and PASS (Not medically necessary)

Not medically necessary

SPS and PASS not medically necessary: Static progressive stretch (SPS) devices and patient-actuated serial stretch (PASS) devices—alone or combined with standard physical therapy—are considered unproven and not medically necessary for treating joint contractures of the upper and lower extremities due to insufficient evidence of efficacy.

Systematic reviews, RCTs, and observational studies report insufficient, inconsistent, or low-quality evidence across indications; further well-designed trials are needed.

Evidence summary: Systematic reviews and meta-analyses have not demonstrated consistent clinical benefit of SPS or other stretch interventions on joint mobility, function, pain, or quality of life; splinting effects on mobility were not superior to comparators in pooled analyses.

Harvey et al. (2017) and other evidence syntheses reported no clear superiority of stretch interventions and overall insufficient evidence supporting SPS/PASS effectiveness.

Indication limitations

Conditional / limited evidence statements

Limitations by joint and condition: Evidence supports LLPS primarily for finger, wrist, elbow, knee, and toe contractures; evidence is minimal or insufficient for other joints and for chronic contractures due to systemic or long-standing conditions (e.g., rheumatoid arthritis, cerebral palsy, plantar fasciitis).

Systematic reviews and RCTs show variable quality, small sample sizes, short follow-up, and limited generalizability to populations with chronic fixed contractures.

Study limitations and follow-up: Available randomized trials have methodological limitations (small sample sizes, incomplete follow-up, lack of blinding, short-term outcomes) and some LLPS trials show small ROM gains that may not translate to improved function.

Teytelbaum RCT had COVID-related follow-up losses and other limitations; Hayes review found fair-to-low quality of evidence and small treatment benefits for finger contractures.

Dose–response evidence for LLPS: For lower-extremity contractures, aggregate data suggest a positive correlation between total hours of prolonged passive stretching and restored active ROM, but clinical applicability varies by joint and study quality.

Evidence-based coverage conclusion

Summary coverage stance from clinical evidence

Overall evidence conclusion: Overall, clinical evidence supports coverage of low-load prolonged-duration stretch (LLPS) devices as an adjunct to therapy for select joint contractures (finger, wrist, elbow, knee, toe).

In contrast, static progressive stretch (SPS) and patient-actuated serial stretch (PASS) devices lack sufficient evidence to establish effectiveness and are considered not medically necessary.

Research gaps: High-quality randomized trials with adequate sample sizes, long-term follow-up, and functional outcome measures are needed to clarify comparative effectiveness across devices and indications.

Existing systematic reviews and single trials report mixed results and methodological limitations that preclude broad conclusions for SPS and PASS.

Use of dynamic low-load prolonged-duration stretch (LLPS) devices is intended to address persistent joint stiffness or contracture that may remain after injury or surgery by providing prolonged, low-load mobilization as an adjunct to an active rehabilitation program. LLPS devices have supporting evidence from randomized controlled trials, observational studies, case series, and medical-community experience for use in the finger, wrist, elbow, knee, and toe. Evidence is limited or minimal for other joints or for contractures arising from chronic systemic conditions (for example, rheumatoid arthritis, cerebral palsy, or plantar fasciitis), and those uses are not supported by sufficient published evidence.

The policy lists specific HCPCS E-codes for reference but notes that certain codes are not on the State of North Carolina Medicaid Fee Schedule and therefore are not covered for NC Medicaid members. Providers should verify state and contractual coverage and understand that the presence of a code in this policy does not guarantee coverage; required medical record documentation may be requested to determine medical necessity.

Static progressive stretch (SPS) and patient-actuated serial stretch (PASS) devices are distinct from dynamic LLPS systems and are considered alternative mechanical approaches to increasing joint range of motion. These devices may be used alone or in combination with standard physical therapy, but when provided they are intended to supplement—rather than replace—therapist-directed rehabilitation by delivering additional joint stretching outside of clinic sessions.

Clinical evidence to support the safety and effectiveness of SPS and PASS devices for treatment of joint contractures is insufficient. Systematic reviews, observational studies, and randomized trials cited in the evidence base do not consistently demonstrate benefit, and reviewers have concluded that well‑designed, adequately powered clinical trials are needed before these approaches can be considered medically necessary.

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.

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Applicable HCPCS codes not on NC Medicaid Fee ScheduleHCPCSNot Covered

E1800	HCPCS code listed as not on NC Medicaid Fee Schedule
E1801	HCPCS code listed as not on NC Medicaid Fee Schedule
E1802	HCPCS code listed as not on NC Medicaid Fee Schedule
E1803	HCPCS code listed as not on NC Medicaid Fee Schedule
E1804	HCPCS code listed as not on NC Medicaid Fee Schedule
E1805	HCPCS code listed as not on NC Medicaid Fee Schedule
E1806	HCPCS code listed as not on NC Medicaid Fee Schedule
E1807	HCPCS code listed as not on NC Medicaid Fee Schedule
E1808	HCPCS code listed as not on NC Medicaid Fee Schedule
E1810	HCPCS code listed as not on NC Medicaid Fee Schedule

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Applicable HCPCS codes not on NC Medicaid Fee ScheduleHCPCSNot Covered

E1800	HCPCS code listed as not on NC Medicaid Fee Schedule
E1801	HCPCS code listed as not on NC Medicaid Fee Schedule
E1802	HCPCS code listed as not on NC Medicaid Fee Schedule
E1803	HCPCS code listed as not on NC Medicaid Fee Schedule
E1804	HCPCS code listed as not on NC Medicaid Fee Schedule
E1805	HCPCS code listed as not on NC Medicaid Fee Schedule
E1806	HCPCS code listed as not on NC Medicaid Fee Schedule
E1807	HCPCS code listed as not on NC Medicaid Fee Schedule
E1808	HCPCS code listed as not on NC Medicaid Fee Schedule
E1810	HCPCS code listed as not on NC Medicaid Fee Schedule

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inv-11: Minimum duration of symptoms/follow-up in cited RCT (key value)

Minimum follow-up in cited RCTMinimum 12 months follow-up in Teytelbaum et al. (2024) RCT

Study population34 patients with idiopathic adhesive capsulitis

ComparatorsHome high-intensity stretch (HIS) device vs physical therapy (PT) vs HIS+PT

Primary outcomes measuredPassive ROM, ASES, and SST scores

inv-12: Functional ROM threshold (e.g., >= 110° after TKA) — key value

Functional ROM threshold used≥ 110° defined as functional ROM after TKA (Rauzi et al., 2022)

Provider Actions and Requirements

Billing Rule

Code listing reference

The following lists of procedure and/or diagnosis codes are provided for reference only and may not be all inclusive. Inclusion of a code in this policy does not imply that the service described by the code is a covered or non‑covered health service, nor does it guarantee reimbursement or payment. Benefit coverage is determined by federal, state, or contractual requirements and applicable law; providers should verify member benefits and the applicable fee schedule for coverage and billing guidance.

Listing of a code does not imply coverage or guarantee claim payment. Verify member benefits, contract, and state fee schedule.

Billing Rule

State-specific code coverage note — North Carolina Medicaid

Providers should verify state-specific coverage and fee schedules before billing. For the State of North Carolina Medicaid program, the HCPCS codes listed in the policy (including but not limited to 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, and E1840) are not on the North Carolina Medicaid Fee Schedule and therefore are not covered by NC Medicaid. Providers must verify state fee schedules and member eligibility prior to providing or billing for services.

Background

A joint contracture is a reduction in passive and active range of motion caused by structural changes in periarticular soft tissues and may result from immobilization after surgery, trauma, or disease. Mechanical stretching devices—including LLPS, SPS, and PASS systems—are used to prevent or treat contractures by providing controlled joint mobilization, often as a home adjunct to formal physical therapy, with the goal of improving range of motion and function.

Definitions

inv-22: Low-load prolonged-duration stretch (LLPS) devices — definition/key attributes

DefinitionAdjustable spring-loaded dynamic splinting systems designed to provide prolonged low-load stretch while the individual is at rest or asleep; available prefabricated or custom for various joints.

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

PurposeUsed to prevent or treat joint contractures and to restore or maintain joint ROM as an adjunct to therapy

CustomizationCustom units may be used when prefabricated units are inadequate due to limb size, required load, or material needs

inv-23: Static progressive stretch (SPS) devices — definition/key attributes

DefinitionSplinting devices that hold the joint in a set position and allow manual modification of the joint angle (inelastic traction); do not allow active or passive motion.

OpenPayer

Mechanical Stretching Devices (for North Carolina Only)

Coverage Criteria

Coding

Provider Actions and Requirements

Background

Definitions