E1805 — Dynamic adjustable wrist extension and flexion device, includes soft interface material
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- 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.
- Documentation of prior history of motion stiffness/loss for members receiving a device in the acute post-operative period after a second or subsequent surgery/procedure.
- Evidence that device use is adjunctive to occupational therapy or physical therapy (notes/orders from OT/PT and evidence of ongoing PT/OT).
Key Coverage Criteria
- 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.
- Dynamic splinting devices used as an adjunct to occupational therapy or physical therapy in members with documented signs and symptoms of significant motion stiffness/loss in the sub-acute injury or post-operative period (i.e., at least 3 weeks after injury or surgery).
- Dynamic splinting devices for members who have a prior documented history of motion stiffness/loss in a joint, have had a surgery or procedure done to improve motion to that joint, and are in the acute post-operative period following a second or subsequent surgery or procedure.
- Coverage tied to applicable CPT/HCPCS codes when the above selection criteria are met (examples of covered CPT codes: 29126, 29131, 29505, 29515; examples of covered HCPCS codes: E1800, E1802, E1805, E1810, E1815, E1825, E1830, E1831).
- Covered ICD-10 diagnosis codes when selection criteria are met include contracture, ankle and foot (M24.571 - M24.576).
4 Active Policies
AMBETTER-CP.MP.144 — Mechanical Stretching Devices for Joint Stiffness and Contracture
AETNA-CPB-0009 — Orthopedic Casts, Braces and Splints
AETNA-CPB-0405 — Mechanical Stretching Devices for Contracture and Joint Stiffness
ANTHEM-CG-DME-39 — CG-DME-39 Dynamic Low-Load Prolonged-Duration Stretch Devices
Related Codes
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