Mechanical Stretching Devices for Joint Stiffness and Contracture

This policy covers use and rental of mechanical stretching devices—principally long‑length progressive stretch (LLPS) and select static progressive stretch (SPS) devices—to prevent or treat joint contractures and restore passive range of motion as an adjunct to physical therapy/home exercise for patients with persistent, functionally limiting stiffness of the toe, knee, elbow, wrist, ankle, or finger. Coverage is limited to the subacute/post‑operative window (≥3 weeks to ≤4 months after injury/operation), requires physician/therapist documentation of meaningful functional limitation and failure of other interventions, supports LLPS for knee, elbow, wrist and extensor tendon finger injuries and SPS for the elbow, and excludes PASS, bi‑directional SPS, and other unsupported devices/indications; rentals are initially limited to four weeks with a single four‑week extension only if improvement is documented.

"Prevention and treatment of joint contractures of the extremities to maintain or restore range of motion (ROM)."