Clinical Policy: Mechanical Stretching Devices for Joint Stiffness and Contracture Form

# Clinical Policy: Mechanical Stretching Devices for Joint Stiffness and Contracture
Reference Number: CP.MP.144
Date of Last Revision: 10/25

[Coding Implications](Coding Implications) [Revision Log](Revision Log)

See [Important Reminder](Important Reminder) at the end of this policy for important regulatory and legal information.

**Description**  
Mechanical stretching devices are used for the prevention and treatment of joint contractures of the extremities with the goal to maintain or restore range of motion (ROM) to the joint. A variety of mechanical stretching devices are available for extension or flexion of the shoulder, elbow, wrist, fingers, knee, ankle, and toes. These devices are generally used as adjunct treatment to physical therapy and/or exercise.

**Policy/Criteria**  
  

II. It is the policy of health plans affiliated with Centene Corporation that the current research does not support the use of any of the following over other currently available alternatives:  
A. LLPS for any indication not noted in section I;  
B. Bi-directional static progressive stretch (SPS) devices¹⁷,¹⁸;  
C. Patient-actuated serial stretch (PASS) devices¹⁸.  

**Background**  
A joint contracture is characterized by chronically reduced range of motion (ROM) secondary to structural changes in non-bony tissues, including muscle, tendons, ligaments, and skin. Prolonged immobilization of joints following surgery or trauma is the most common cause of joint contractures. A number of different modalities are used to treat or prevent joint contractures.

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# Clinical Policy  
Mechanical Stretching Devices for Joint Stiffness and Contracture

Mechanical stretching devices have been researched for the treatment of joint contractures. The use of these devices is based on the theory that passive motion early in the healing process can promote movement of the synovial fluid, and thus promote lubrication of the joint; stimulate the healing of articular tissues; prevent adhesions and joint stiffness; and reduce edema without interfering with the healing of incisions or wounds over the moving joint.

Several types of devices exist, including low-load prolonged duration stretch (LLPS) devices (also referred to as dynamic splinting), static progressive stretch (SPS) devices, and patient-actuated serial stretch (PASS) (also known as patient-directed serial stretch) devices.  
- LLPS devices permit resisted active and passive motion (elastic traction) within a limited range. LLPS devices maintain a set level of tension by means of incorporated springs.  
- SPS devices hold the joint in a set position but allow for manual modification of the joint angle and may allow for active motion without resistance (inelastic traction). This type of device itself does not exert a stress on the tissue unless the joint angle is set at the maximum ROM.  
- PASS devices permit resisted active and passive motion within a limited range utilizing pneumatic or hydraulic systems that can be adjusted by the patient. The extensionaters use pneumatic systems while the flexionaters use hydraulic systems. These devices require custom fitting.

Mechanical stretching devices are commonly used in the post-operative period, following an injury or when addressing joint stiffness in the knee, ankle, toe, shoulder, elbow, wrist, or finger. Peer reviewed studies researching mechanical stretching devices are limited. The best evidence is available in studies evaluating LLPS when used at the knee, elbow, wrist, and following extensor tendon injuries of the finger and for SPS when used at the elbow.

Several authors have looked at the implementation of dynamic splinting at the finger following an extensor tendon repair.¹,²,³,⁴,⁵,⁶,⁷ Results from a small, prospective, randomized trial comparing dynamic splinting to static splinting suggest that dynamic splinting of complex lacerations of the extensor tendons in zones V through VII provides improved functional outcomes at four and 12 weeks and six months when compared with static splinting.¹ Another small, prospective, randomized, controlled study comparing postoperative dynamic versus static splinting outcomes of patients following extensor tendon repair reported dynamic splinting of simple, complete lacerations of the extensor tendons in zones V and VI. Dynamic splinting provided improved functional outcomes at four, six, and eight weeks but not by six months when compared with static splinting.²

Dynamic splinting and static progressive stretch devices have both been applied at the elbow in isolation and in comparison to one another. In 2004 Gallucci and colleagues looked at a sample of 30 patients who were at least 78 days after surgery or trauma and had a functional arc of movement of less than 100 degrees at the elbow. They found that two thirds of patients were able to achieve at least a 100 degree arc and therefore, improved function after using a dynamic splint for 75 days.³ In a 2009 randomized controlled pilot study of 30 patients, Lai and colleagues found significant improvements in ROM when dynamic splinting was added to the control treatment of botulinum toxin type-A and occupational therapy treatment.⁴ Studies in 2010 by

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# Clinical Policy  
Mechanical Stretching Devices for Joint Stiffness and Contracture

Bhat and colleagues found similar benefits to SPS at the elbow.¹⁰ The SPS device was introduced to the patient approximately 4.5 to five months after injury or surgery and once improvements from therapy were stagnant. A functional ROM or arc of movement was achieved in 19 out of 30 patients.¹⁰ In 2006, Doornberg and colleagues also demonstrated improvements with ROM overall after SPS intervention but noted that early splinting after the initial injury rather than after elbow encapsellectomy yielded greater results.¹¹ In 2012, Lindenhovius and colleagues performed a prospective randomized controlled trial looking at the benefit of dynamic splinting versus SPS in improving range of motion and function as measured by the Disabilities of the Arm, Shoulder, and Hand (DASH).¹² No significant difference was found between the two groups prior to treatment or after three, six or 12 month follow-ups.¹² Additionally in 2015, Veltman and colleagues completed a systematic review on the topic which included the results from 232 patients with a similar outcome showing that each device was beneficial but that one was not more effective than the other.¹³

At the knee and wrist, dynamic splinting has been identified as beneficial when further progression of ROM is needed after surgery or an injury. In 2018, Pace and colleagues performed a Level IV retrospective study, looking at the implementation of dynamic splinting following knee surgery in 74 adolescents and children who had ROM deficits in flexion, extension, and both directions.¹⁴ As a result of this study, 84% of the patients experienced a significant increase in ROM, and 58% were able to avoid further surgical intervention. In 2016, Willis and colleagues looked at the treatment of carpal tunnel syndrome using dynamic splinting at the wrist.¹⁵ They performed a randomized control trial where the experimental group was provided with dynamic splinting in addition to anti-inflammatories and a stretching program. Those patients who received dynamic splinting in addition to the other treatments had a significant decline in the need for surgical intervention after conservative management was complete. Similarly, Glasgow and colleagues in 2011 looked at the effect of dynamic splinting at the hand and forearm respectively and demonstrated improvements in ROM after injury in both areas.¹⁶

A variety of randomized control trials, observational studies, case series, and medical community acceptance confirms the benefits of dynamic LLPS devices at the knee, elbow, wrist, and fingers when used to relieve persistent joint stiffness that can occur after injury or surgery.

While additional evidence is emerging, there is insufficient evidence in the published peer-reviewed literature to support the use of dynamic LLPS at other joints to including the foot and shoulder. There is insufficient evidence in the published medical literature to demonstrate the safety, efficacy, and long-term outcomes on the use of patient-actuated serial stretch (PASS) devices.

**Coding Implications**  
This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2024, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage.

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# Clinical Policy  
Mechanical Stretching Devices for Joint Stiffness and Contracture

Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services.

| HCPCS Codes | Description |
|-------------|-------------|
| E1800 | Dynamic adjustable elbow extension/flexion device, includes soft interface material |
| E1802 | Dynamic adjustable forearm pronation/supination device, includes soft interface material |
| E1803 | Dynamic adjustable elbow extension only device, includes soft interface material |
| E1804 | Dynamic adjustable elbow flexion only device, includes soft interface material |
| E1805 | Dynamic adjustable wrist extension/flexion device, includes soft interface material |
| E1807 | Dynamic adjustable wrist extension only device, includes soft interface material |
| E1808 | Dynamic adjustable wrist flexion only device, includes soft interface material |
| E1810 | Dynamic adjustable knee extension/flexion device, includes soft interface material |
| E1812 | Dynamic knee, extension/flexion device with active resistance control |
| E1813 | Dynamic adjustable knee extension only device, includes soft interface material |
| E1814 | Dynamic adjustable knee flexion only device, includes soft interface material |
| E1815 | Dynamic adjustable ankle extension/flexion device, includes soft interface material |
| E1820 | Replacement soft interface material, dynamic adjustable extension/flexion device |
| E1822 | Dynamic adjustable ankle extension only device, includes soft interface material |
| E1823 | Dynamic adjustable ankle flexion only device, includes soft interface material |
| E1825 | Dynamic adjustable finger extension/flexion device, includes soft interface material |
| E1826 | Dynamic adjustable finger extension only device, includes soft interface material |
| E1827 | Dynamic adjustable finger flexion only device, includes soft interface material |
| E1828 | Dynamic adjustable toe extension only device, includes soft interface material |
| E1829 | Dynamic adjustable toe flexion only device, includes soft interface material |

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# Clinical Policy  
Mechanical Stretching Devices for Joint Stiffness and Contracture

| HCPCS Codes | Description |
|-------------|-------------|
| E1830 | Dynamic adjustable toe extension and flexion device, includes soft interface material |

| HCPCS Codes that do not support coverage criteria | |
|-----------------------------------------------|-------------|
| HCPCS Codes | Description |
| E1399 | Durable medical equipment, miscellaneous |
| E1801 | Static progressive stretch elbow device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories |
| E1806 | Static progressive stretch wrist device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories |
| E1811 | Static progressive stretch knee device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories |
| 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 |
| E1831 | Static progressive stretch toe device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories |
| E1832 | Static progressive stretch finger 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 |

| Reviews, Revisions, and Approvals | Revision Date | Approval Date |
|----------------------------------|---------------|---------------|
| Policy developed. | 04/17 | 04/17 |
| Adapted criteria from WellCare’s Dynamic Stretching Devices for Treatment of Joint Stiffness and Contracture HS164. For LPSS, added knee, elbow, and wrist injuries as medically necessary indications. Specified that criteria IA-I.B be met for LPSS. Removed indication of members/enrollees unable to benefit from standard physical therapy modalities because of inability to exercise, from original HS164 criteria. Changed the not medically necessary statements regarding LPSS for other indications, PASS and SPS devices to experimental/investigational. Added the following HCPCS codes as supporting coverage criteria: E1800, E1802, E1805, E1810, E1812. Removed HCPCS table of codes not supporting medical necessity. Replaced existing ICD-10 codes with the following: M24.521 – M24.529, M24.531 – M24.539, M24.541 | 04/20 | 04/20 |

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# Clinical Policy  
Mechanical Stretching Devices for Joint Stiffness and Contracture

| Reviews, Revisions, and Approvals | Revision Date | Approval Date |
|----------------------------------|---------------|---------------|
| - M24.549, M24.561 - M24.569, M25.621 - M25.629, M25.631 - M25.639, M25.641 - M25.649, M25.661 - M25.669. <br> Added a table of HCPCS codes not supporting medical necessity, including the following codes: E1399, E1801, E1806, E1811, E1815, E1816, E1818, E1830, E1831, E1840, E1841. | 06/20 |  |
| Combined sections II-IV into II and replaced “Experimental/investigational” verbiage with descriptive language. Minor updates to background with no impact on criteria. Replaced all instances of “member” with “member/enrollee.” References reviewed and updated. Codes reviewed. | 03/21 | 04/21 |
| Annual review. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” <br> References reviewed, updated and reformatted. Reviewed by specialist. | 12/21 | 12/21 |
| Annual review. Background updated with no impact on criteria. Removed ICD-10 codes. References reviewed and updated. Reviewed by internal specialist and external specialist. | 11/22 | 11/22 |
| Annual review. Added ankle to Criteria I. Rearranged Criteria IA. for clarification and added Criteria IA.1.c. stating that low-load prolonged-duration stretch (LLPS) device/dynamic stretch device is provided with or without adjunctive physical therapy. Specified in I.B. that criteria is for a rental. Minor rewording in Background section with no impact on policy criteria. Removed code E1815 from HCPCS codes that do not support coverage and added to HCPCS codes that do support coverage. References reviewed and updated. Reviewed by internal specialist. | 11/23 | 11/23 |
| Annual review. Background updated with no impact on criteria. References reviewed and updated. Reviewed by internal specialist. | 10/24 | 10/24 |
| Added new HCPCS codes E1803, E1804, E1807, E1808, E1813, E1814, E1822, E1823, E1826, and E1827 to policy. <br> Annual review. Added “toe” to criteria under I. Under IA.1.a. added “therapist”. Reworded criteria under IA.1.c. with no impact to criteria. Added CPT codes E1820, E1828, E1829, E1832. Removed E1830 from the “does not support” HCPCS and added to “supports”. References reviewed and updated. Reviewed by internal and external specialist. | 03/25 <br> 10/25 | 03/25 <br> 10/25 |

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# Clinical Policy  
Mechanical Stretching Devices for Joint Stiffness and Contracture



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# Clinical Policy  
Mechanical Stretching Devices for Joint Stiffness and Contracture

**Important Reminder**  
This clinical policy has been developed by appropriately experienced and licensed health care professionals based on a review and consideration of currently available generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by this clinical policy; and other available clinical information. The Health Plan makes no representations and accepts no liability with respect to the content of any external information used or relied upon in developing this clinical policy. This clinical policy is consistent with standards of medical practice current at the time that this clinical policy was approved. “Health Plan” means a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan’s affiliates, as applicable.

The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy,

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# Clinical Policy  
Mechanical Stretching Devices for Joint Stiffness and Contracture

contract of insurance, etc.), as well as to state and federal requirements and applicable Health Plan-level administrative policies and procedures.

This clinical policy is effective as of the date determined by the Health Plan. The date of posting may not be the effective date of this clinical policy. This clinical policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this clinical policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. The Health Plan retains the right to change, amend or withdraw this clinical policy, and additional clinical policies may be developed and adopted as needed, at any time.

This clinical policy does not constitute medical advice, medical treatment or medical care. It is not intended to dictate to providers how to practice medicine. Providers are expected to exercise professional medical judgment in providing the most appropriate care, and are solely responsible for the medical advice and treatment of members/enrollees. This clinical policy is not intended to recommend treatment for members/enrollees. Members/enrollees should consult with their treating physician in connection with diagnosis and treatment decisions.

Providers referred to in this clinical policy are independent contractors who exercise independent judgment and over whom the Health Plan has no control or right of control. Providers are not agents or employees of the Health Plan.

This clinical policy is the property of the Health Plan. Unauthorized copying, use, and distribution of this clinical policy or any information contained herein are strictly prohibited. Providers, members/enrollees and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, members/enrollees and their representatives agree to be bound by such terms and conditions by providing services to members/enrollees and/or submitting claims for payment for such services.

**Note:** For Medicaid members/enrollees, when state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this clinical policy.

**Note:** For Medicare members/enrollees, to ensure consistency with the Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), all applicable NCDs, LCDs, and Medicare Coverage Articles should be reviewed prior to applying the criteria set forth in this clinical policy. Refer to the CMS website at http://www.cms.gov for additional information.



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