Medical Policy: 01.01.16 
Original Effective Date: March 2009 
Reviewed: January 2016 
Revised: January 2016 


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:

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:

  • 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®, Dynasplint Trismuss System®, EMPI Advance Dynamic ROM®, LMB Pro-GlideTM.
  • Bi-directional static progressive stretch (SPS) 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 JAS EZ Shoulder ROM, JAS EZ Elbow ROM, JAS EZ Pronation-Supination ROM, JAS EZ Wrist ROM and JAS EZ Finger ROM) and Air Cast®.
  • 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®.

The use of dynamic splinting devices are proven for improvement of range of motion after surgery or injury when physical therapy alone has not been effective. The use is limited to joints of the knee, elbow, toe, finger, and wrist. Use in other joints has  not been proven at this time.


Prior Approval:

 

Not applicable


Policy:

Dynamic Splinting devices will  be considered medically necessary for those with contractures of the following joints, caused by injury or joint stiffness of the following joints:

  • Knee
  • Elbow
  • Toe
  • Finger
  • Wrist

Only after a trial of physical therapy has been ineffective in improving range of motion.

 

The use of dynamic splinting devices are limited to four months of use.

 

Dynamic splinting devices (dynamic (low-load prolonged stretch [LLPS]) devices are considered investigational for use with joints other than knee, elbow, toe, finger, and wrist.   

 

Dynamic splinting devices (dynamic (low-load prolonged stretch [LLPS]) devices which are specific to the ankle and shoulder are considered investigational for all indications including but not limited to the management of chronic joint stiffness or chronic fixed contractures due to trauma, fractures, burns, head and spinal cord injury, rheumatoid arthritis, multiple sclerosis, muscular dystrophy, or cerebral palsy.  Based on peer reviewed literature there is lack of scientific evidence regarding the safety and effectiveness of dynamic splinting for these indications.

 

The use of dynamic splinting devices are not appropriate and are unproven in the pediatric population.  Dynamic splinting devices are investigational for pediatrics.

 

The use of dynamic splinting devices are not appropriate and unproven in the use of chronic conditions including, but not limited to: contractures from chronic conditions, arthritis.

 

Dynamic splinting is considered investigational for the following indications (this is not an all inclusive list):

  • Carpal tunnel syndrome
  • Cerebral palsy and congenital quadriplegia
  • Epilepsy
  • Foot drop associated with neuromuscular diseases
  • Head and spinal cord injuries
  • Multiple sclerosis
  • Muscular dystrophy
  • Plantar Fasciitis
  • Rheumatoid arthritis
  • Stroke
  • Trismus
  • Bunion
  • Halux valgus or halux rigidus
  • Injuries of ankle and shoulder
  • Burns
  • Temporomandibular Joint Disease (TMJ)
  • Contractures due to chronic disease

Based on peer reviewed literature there is lack of scientific evidence regarding the safety and effectiveness of dynamic splinting for these indications and therefore, is considered investigational

 

Bi-directional static progressive stretch (SPS) devices are considered investigational for all indications.  Clinical evidence is not sufficient to demonstrate that use of static progressive or patient actuated devices is a safe or effective treatment option.  Studies are limited to small sample sizes.  Based on peer review literature clinical evidence is not sufficient to demonstrate that the use of a static progressive stretch device improves long-term patient outcomes. Evidence is limited to primarily short term outcomes and lack of comparison to other treatment modalities and therefore is considered investigational for all indications.  

 

Patient-actuated serial stretch (PASS) devices are considered investigational for all indications.

 

Based on peer reviewed literature, there is lack of published studies investigating PASS devices, no conclusion can be drawn regarding their efficacy. Therefore, patient-actuated serial stretch (PASS) devices are considered investigational for all indications.



Procedure Codes and Billing Guidelines:

  • To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis codes.
  • E1700 Jaw motion rehabilitation system
  • E1701 Replacement cushions for jaw motion rehabilitation system, package of 6
  • E1702 Replacement measuring scales for jaw motion rehabilitation system, package of 200 
  • E1800 Dynamic adjustable elbow extension/flexion device includes soft interface material
  • E1801; Static progressive stretch elbow device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories
  • E1802 Dynamic adjustable forearm pronation/supination device, includes soft interface material
  • E1805 Dynamic adjustable wrist extension/flexion device,includes soft interface material
  • E1806; Static progressive stretch wrist device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories
  • E1810 Dynamic adjustable knee extension/flexion device, includes soft interface material
  • E1811; Static progressive stretch knee device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories
  • E1812 Dynamic knee, extension/flexion device with active resistance control
  • E1815; Dynamic adjustable ankle extension/flexion device, includes soft interface material
  • E1816; Static progressive stretch ankle device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories
  • E1818; Static progressive stretch forearm pronation/supination device, with or without range of motion adjustment, includes all components and accessories
  • E1821; Replacement soft interface material/cuffs for bi-directional static progressive stretch device
  • E1825 Dynamic adjustable finger extension/flexion device, includes soft interface material
  • E1830 Dynamic adjustable toe extension/flexion device, includes soft interface material
  • E1831 Static progressive stretch toe device, extension and/or flexion with or without range of motion adjustment,  includes all components and accessories 
  • E1840; Dynamic adjustable shoulder flexion/abduction/rotation device, includes soft interface material
  • E1841; Static progressive stretch shoulder device, with or without range of motion adjustment, includes all components and accessories
  • E1399 Durable medical equipment, miscellaneous (Patient actuated serial stretch (PASS) device)

Selected References:

  • 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.
  • 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.
  • Branch TP, Karsch RE, Mills TJ, Palmer MT. Mechanical therapy for loss of knee flexion. Am J Orthop. 2003;32(4):195-200.
  • Doornberg JN, Ring D, Jupiter JB. Static progressive splinting for posttraumatic elbow stiffness. J Orthop Trauma. 2006 July;20(6):400-4.
  • ECRI. Mechancial Stretching Devices (ERMI Flexionaters and Extensionaters) for Contracture and Joint Stiffness. Plymouth Meeting (PA): ECRI Health Technology Information Service External Site2007 March 27. 5 p. (ECRI Hotline Response).
  • 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.
  • ECRI. Joint Active Systems (JAS) Devices for Improving Range of Motion in Injured Joints. Plymouth Meeting (PA): ECRI Health Technology Information Service External Site2007 October 12. (ECRI Hotline Response).
  • ECRI. Mechanical Stretching Devices (ERMI Flexionaters and Extensionaters) for Contracture and Joint Stiffness. Plymouth Meeting (PA): ECRI Health Technology Information Service External Site2011 March 22. (ECRI Hotline Response).
  • Glasgow C, Tooth LR, Fleming J, Peters S. Dynamic splinting for the stiff hand after trauma: predictors of contracture resolution External SiteJ Hand Ther. 2011 Jul-Sep;24(3):195-205.
  • 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.
  • 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 External SiteJ Hand Ther. 2012 Jan;25(1):38-47.
  • Ibraham M., Donatelli R., Hellman M., Echternach J. Efficacy of a Static Progressive Stretch Device as an Adjunct to Physical Therapy in Treating Adhesive Capsulitis of the Shoulder: A prospective, Randomized Study External Site
  • Mahmoud I Ibrahim, Aaron J. Johnson et. al Treatment of Adhesive Capsulitis of the Shoulder with a Static Progressive Stretch Device: A Prospective Randmized Study. JLTMI; April 2013; Vol2294) 281-291.
  • Aaron J. Johnson, Shelton A McKensi et. al Assessment of Static Progressive Stretch for Treatment of Shoulder Stiffness. A Prospective Case Series. JLTMI; April2013;Vol22(4) 293-303.
  • Anneluuk Lindenhovius, M.D., PhD, Job Doornberg M.D.,PhD et. al A Prospective Randomized Controlled Trial of Dynamic Versus Static Progressive Elbow Splinting for Post-Traumatic Elbow Stiffness. J Bone Joint Surg Am: April 2012;Vol 94-A (8) 694-700.
  • Dempsey AL, Branch TP, Mills T, et al. High-intensity mechanical therapy for loss of knee extension for worker's compensation and non-compensation patients. Sports Med Arthrosc Rehabil Ther Technol. 2010;2:26. PMID 20939921
  • Lucado AM, Li Z, Russell GB, et al. Changes in impairment and function after static progressive splinting for stiffness after distal radius fracture. J Hand Ther. Oct-Dec 2008;21(4):319-325. PMID 19006757
  • Veltman ES, Doornberg JN, Eygendaal D, et al. Static progressive versus dynamic splinting for posttraumatic elbow stiffness: A systematic review of 232 patients. Arch Orthop Trauma Surg. 2015 Mar 13

Policy History:

  • January 2016 - Annual Review, Policy Revised
  • January 2015 - Annual Review, Policy Revised
  • February 2014 - Annual Review, Policy Revised
  • February 2013  - Annual Review, Policy Revised
  • February 2012 - Annual Review, Policy Revised
  • October 2011 - Annual Review, Policy Renewed
  • August 2010 - Annual Review, Policy Renewed

 


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.