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

This policy addresses dynamic low-load prolonged-duration stretch (LLPS) devices (e.g., Dynasplint, JAS Dynamic) used to provide sustained stretch to improve joint range of motion. Coverage is medically necessary only when plan criteria are met for use on the elbow, finger, knee, or wrist, with continued coverage contingent on documented improvement within the first 4 months. These devices are not covered for any other joints or conditions (including chronic stiffness or fixed contractures) or when there is no significant improvement after 4 months, including in individuals unable to participate in standard therapy.

"Dynamic LLPS devices are consideredmedically necessarywhen criteria A, B and C below have been met:"

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