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
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- 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; refer to the protocol titled 'Medical Records Documentation Used for Reviews.'
- Benefit coverage is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service; when deciding coverage, the member specific benefit plan document must be referenced as plan terms may differ from the standard plan.
- Documented signs and symptoms of significant motion stiffness/loss (clinical notes describing limitation in ROM and functional impact).
- Documentation of timing relative to injury or surgery: either at least 3 weeks after injury or surgery (sub-acute/post-operative period) when used as adjunct to OT/PT, or documentation that the member is in the acute post-operative period following a second or subsequent surgery/procedure for that joint when there is a prior documented history of motion stiffness/loss.
Key Coverage Criteria
- 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.
- LLPS (dynamic splinting) devices to relieve persistent joint stiffness that can occur after injury or surgery.
- Use of dynamic LLPS devices for restoration of joint range of motion (ROM) for joints including (but not necessarily limited to) finger, wrist, elbow, knee, and toe where evidence supports benefit.
- Custom dynamic splinting systems when effective treatment cannot be provided with prefabricated units (e.g., limb size/shape or necessary load/material requirements).
- Dynamic adjustable ankle extension/flexion device (e.g., JAS Ankle) for the treatment of contractures (refer to CPB 0565 - Ankle Orthoses, Ankle-Foot Orthoses (AFOs), and Knee-Ankle-Foot Orthoses (KAFOs)).
- Dynamic splinting devices as durable medical equipment (DME) for the knee, elbow, wrist, finger, or toe when selection criteria are met.
6 Active Policies
AMBETTER-CP.MP.144 — Mechanical Stretching Devices for Joint Stiffness and Contracture
AETNA-CPB-0405 — Mechanical Stretching Devices for Contracture and Joint Stiffness
ANTHEM-DME.00038 — DME.00038 Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices
UHC-POL-mechanical-stretching-devices — Mechanical Stretching Devices
UMR-POL-UMR-mechanical-stretching-devices
Related Codes
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