E1804, Dynamic adjustable elbow flexion only device, includes soft interface material
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high 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.
- 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.
- Records showing prior interventions (e.g., physical therapy) and documentation that the member did not respond.
Key Coverage Criteria
- 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
- Clinical settings:During the subacute injury or post-operative period (greater than or equal to 3 weeks but less than or equal to 4 months after injury or operation);andAs an addition to physical or occupational therapy in in individuals with signs and symptoms of persistent joint stiffness or contracture;orThe individualâs limited range of motion poses a meaningful (as judged by the physician) functional limitation, AND who has not responded to other therapy (including physical or occupationa [...]
- During the subacute injury or post-operative period (greater than or equal to 3 weeks but less than or equal to 4 months after injury or operation);andAs an addition to physical or occupational therapy in in individuals with signs and symptoms of persistent joint stiffness or contracture;orThe individualâs limited range of motion poses a meaningful (as judged by the physician) functional limitation, AND who has not responded to other therapy (including physical or occupational therapy);or
- As an addition to physical or occupational therapy in in individuals with signs and symptoms of persistent joint stiffness or contracture;or
- The individualâs limited range of motion poses a meaningful (as judged by the physician) functional limitation, AND who has not responded to other therapy (including physical or occupational therapy);or
5 Active Policies
ANTHEM-CG-DME-39, CG-DME-39 Dynamic Low-Load Prolonged-Duration Stretch Devices
UHC-POL-mechanical-stretching-devices, Mechanical Stretching Devices
AMBETTER-CP.MP.144, Mechanical Stretching Devices for Joint Stiffness and Contracture
UMR-POL-UMR-mechanical-stretching-devices, Mechanical Stretching Devices
SUREST-POL-SUREST-mechanical-stretching-devices
Related Codes
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