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Medical Policy: 01.01.16
Original Effective Date: March 2009
Reviewed: February 2012
Revised: February 2012
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Joint stiffness or contracture may be caused by immobilization following trauma, surgery or disease. Characteristics of a joint contracture are persistently reduced range of motion (ROM) as a result of structural changes in muscles, tendons, ligaments, and skin. Joint dysfunction develops when elastic connective tissue is replaced with inelastic fibrous material which results in tissue that resists stretching.
Physical Therapy (PT) procedures and special mechanical stretching devices also referred to as dynamic splinting devices have been developed to increase ROM without damaging the affected joint or its related muscles, tendons, and connective tissue.
Several types of dynamic splinting devices are available:
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Dynamic (low-load prolonged stretch [LLPS]) devices permit resisted active and passive motion within a restricted range. Examples of such devices include but are not limited to Dynasplint System®, EMPI Advance Dynamic ROM®, LMB Pro-GlideTM.
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Bi-directional static progressive (SP) devices maintain the joint in a set position, but permit manual modification of the joint and may allow for active motion without resistance. Examples include but are not limited to Joint Active Systems (JAS) splints (e.g., JAS Elbow, JAS Shoulder, JAS Ankle, JAS Knee, JAS Wrist, and JAS Pronation-Supination) and Air Cast®.
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Patient-actuated serial stretch (PASS) devices allow resisted active and passive motion within a limited range. Examples of PASS devices include the ERMI Knee Extensionater®, ERMI Elbow Extensionater®, ERMI Knee/Ankle Flexionater®, and the ERMI Shoulder Flexionater®.
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Prior Approval:
Not applicable
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Policy:
Dynamic splinting devices (dynamic (low-load prolonged stretch [LLPS]) devices are considered medically necessary for use on the knee, elbow, toe, finger, and wrist for up to 4 months if either of the following criteria is met:
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As an addition to PT in members with documented signs and symptoms of persistent joint stiffness/loss in the sub-acute injury or post-op period (≥ 3 weeks but ≤ 4 months after injury or surgery); OR
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In acute post-op period for members who have a prior documented history of motion stiffness/loss in a joint and are having additional surgery or procedures done to improve motion in that joint.
Dynamic splinting devices (dynamic (low-load prolonged stretch [LLPS]) devices are considered investigational for use on other joints not mentioned above.
Dynamic splinting devices (dynamic (low-load prolonged stretch [LLPS]) devices are considered investigational in the management of chronic joint stiffness or chronic fixed contractures including but not limited to joint trauma, fractures, burns, head and spinal cord injury, rheumatoid arthritis, plantar fasciitis, multiple sclerosis, muscular dystrophy, or cerebral palsy.
Bi-directional static progressive (SP) devices are considered investigational for all indications.
Patient-actuated serial stretch (PASS) devices are considered investigational for all indications.
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Procedure Codes and Billing Guidelines:
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To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
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E1800 Dynamic adjustable elbow extension/flexion device, includes soft interface material
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E1801Static progressive stretch elbow device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories
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E1802 Dynamic adjustable forearm pronation/supination device, includes soft interface material
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E1805 Dynamic adjustable wrist extension/flexion device, includes soft interface material
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E1806 Static progressive stretch wrist device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories
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E1810 Dynamic adjustable knee extension/flexion device, includes soft interface material
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E1811 Static progressive stretch knee device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories
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E1812 Dynamic knee, extension/flexion device with active resistance control
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E1815 Dynamic adjustable ankle extension/flexion device, includes soft interface material
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E1816 Static progressive stretch ankle device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories
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E1818 Static progressive stretch forearm pronation/supination device, with or without range of motion adjustment, includes all components and accessories
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E1820 Replacement soft interface material, dynamic adjustable extension/flexion device
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E1821 Replacement soft interface material/cuffs for bi-directional static progressive stretch device
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E1825 Dynamic adjustable finger extension/flexion device, includes soft interface material
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E1830 Dynamic adjustable toe extension/flexion device, includes soft interface material
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E1840 Dynamic adjustable shoulder flexion/abduction/rotation device, includes soft interface material
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E1841 Static progressive stretch shoulder device, with or without range of motion adjustment, includes all components and accessories
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Selected References:
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McClure PW, Blackburn LG, Dusold C. The use of splints in the treatment of joint stiffness: Biologic rationale and an algorithm for making clinical decisions. Phys Ther. 1994; 74(12):1201-1107.
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Harvey L, Herbert R, Crosbie J. Does stretching induce lasting increases in joint ROM? A systematic review. Physiother Res Int. 2002;7(1):1-13.
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Branch TP, Karsch RE, Mills TJ, Palmer MT. Mechanical therapy for loss of knee flexion. Am J Orthop. 2003;32(4):195-200.
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Doornberg JN, Ring D, Jupiter JB. Static progressive splinting for posttraumatic elbow stiffness. J Orthop Trauma. 2006 July;20(6):400-4.
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ECRI. Mechancial Stretching Devices (ERMI Flexionaters and Extensionaters) for Contracture and Joint Stiffness. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2007 March 27. 5 p. (ECRI Hotline Response). Also available: http://www.ecri.org.
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Bonutti PM, McGrath MS, Ulrich SD, McKenzie SA, Seyler TM, Mont MA. Static progressive stretch for the treatment of knee stiffness. Knee. 2008 Aug; 15(4):272-6.
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ECRI. Joint Active Systems (JAS) Devices for Improving Range of Motion in Injured Joints. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2007 October 12. (ECRI Hotline Response). Also available: http://www.ecri.org.
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ECRI. Mechanical Stretching Devices (ERMI Flexionaters and Extensionaters) for Contracture and Joint Stiffness. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2011 March 22. (ECRI Hotline Response). Also available: http://www.ecri.org.
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Glasgow C, Tooth LR, Fleming J, Peters S. Dynamic splinting for the stiff hand after trauma: predictors of contracture resolution. J Hand Ther. 2011 Jul-Sep;24(3):195-205.
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John MM, Kalish S, Perns SV, Willis FB. Dynamic splinting for postoperative hallux limitus: a randomized, controlled trial. J Am Podiatr Med Assoc. 2011 Jul-Aug;101(4):285-8.
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Glasgow C, Tooth LR, Fleming J, & Peters S. Dynamic splinting for the stiff hand after trauma: Predictors of contracture resolution. J Hand Ther. 2011 Jul-Sep;24(3):195-205.
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Glasgow C, Fleming J, Tooth LR, & Hockey RL. The long-term relationship between duration of treatment and contracture resolution using dynamic orthotic devices for the stiff proximal interphalangeal joint: A prospective cohort study. J Hand Ther. 2012 Jan;25(1):38-47.
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Policy History:
Date Reason Action
August 2010 Annual review Policy renewed
October 2011 Annual review Policy renewed
February 2012 Annual review Policy revised
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.
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