Does E1804 require prior authorization?

No, E1804 does not require prior authorization (high confidence). Code is covered without prior authorization.

`E1804` — Dynamic adjustable elbow flexion only device, includes soft interface material

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

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.
Clinical documentation from physician or therapist stating limited range of motion causes a meaningful functional limitation.
Documentation of injury or operation date to verify the ≥3 weeks and ≤4 months timeframe.

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 LLPS devices are consideredmedically necessarywhen criteria A, B and C below have been met:
For use in the following anatomical locations:Elbow;orFinger;orKnee;orWrist;and

AMBETTER-CP.MP.144 — Mechanical Stretching Devices for Joint Stiffness and Contracture

ANTHEM-CG-DME-39 — CG-DME-39 Dynamic Low-Load Prolonged-Duration Stretch Devices

UHC-POL-mechanical-stretching-devices — Mechanical Stretching Devices

UMR-POL-UMR-mechanical-stretching-devices — Mechanical Stretching Devices

SUREST-POL-SUREST-mechanical-stretching-devices

Ask Verity about documentation requirements, denial risks, or coverage in your state.