405 Form

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Medical Policy Dynamic Low-Load Prolonged-Duration Stretch Devices Table of Contents • Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History

Policy Number: 405 BCBSA Reference Number: N/A NCD/LCD:
Related Policies
• Patient-Controlled End of Range Motion Stretching Devices #721 Policy1 Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity
Medicare HMO BlueSM and Medicare PPO BlueSM Members

Dynamic low-load prolonged-duration stretch (LLPS) devices (including but not limited to: Dynasplint System®, Pro-Glide™, JAS Dynamic, Ultraflex) for the knee, elbow, wrist, and finger are considered MEDICALLY NECESSARY for the following:

• During the subacute injury or post operative period (greater than or equal to 3 weeks but less than or equal to 4 months after the injury or surgery) o Individual has signs or symptoms of persistent joint stiffness, contracture, or limited range of motion causing functional limitations and o Individual has not responded to other therapy (including physical or occupational therapy) or LLPS device is used in conjunction with physical or occupational therapy OR

• During the acute post operative period for individuals who have undergone additional surgery to improve the range of motion of a previously affected joint OR

• For individuals unable to benefit from standard physical or occupational therapy modalities because of an inability to exercise.

Duration of use for dynamic LLPS devices is for an initial period of up to 4 months. Use of dynamic LLPS devices longer than 4 months is MEDICALLY NECESSARY with demonstrated improvement.

Dynamic LLPS devices for postoperative management of tendon repair is considered MEDICALLY NECESSARY.

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Replacement of the soft interface material used with dynamic LLPS devices is considered MEDICALLY NECESSARY when no longer functioning properly.

Continued use of dynamic LLPS devices longer than 4 months duration if no significant improvement in motion is noted is considered NOT MEDICALLY NECESSARY, including but not limited to individuals unable to benefit from standard physical or occupational therapy due to inability to exercise.

Dynamic LLPS devices are considered NOT MEDICALLY NECESSARY for any other joints or indications other than those listed above.

Prior Authorization Information
Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) Prior authorization is not required. Commercial PPO and Indemnity Prior authorization is not required. Medicare HMO BlueSM Prior authorization is not required. Medicare PPO BlueSM Prior authorization is not required.

CPT Codes / HCPCS Codes / ICD Codes
Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable. The above medical necessity criteria MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue, and Medicare PPO Blue: HCPCS codes:

Code Description E1800 Dynamic adjustable elbow extension and flexion 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

The following ICD Diagnosis Codes are considered medically necessary when submitted with the HCPCS codes above if medical necessity criteria are met: ICD-10-CM diagnosis codes: Code Description M24.521 Contracture Right Elbow M24.522 Contracture Left Elbow M24.529 Contracture, unspecified elbow M25.621 Stiffness Of Right Elbow Not Elsewhere Classified M25.622 Stiffness Of Left Elbow Not Elsewhere Classified M25.629 Stiffness of unspecified elbow, not elsewhere classified

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The above medical necessity criteria MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue, and Medicare PPO Blue: HCPCS codes:

Code Description E1802 Dynamic adjustable forearm pronation/supination device, includes soft interface material E1805 Dynamic adjustable wrist extension and 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 E1825 Dynamic adjustable finger extension and 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

The following ICD Diagnosis Codes are considered medically necessary when submitted with the CPT codes above if medical necessity criteria are met: ICD-10-CM diagnosis codes: Code Description M24.531 Contracture, right wrist M24.532 Contracture, left wrist M24.539 Contracture, unspecified wrist M25.631 Stiffness of right wrist, not elsewhere classified M25.632 Stiffness of left wrist, not elsewhere classified M25.639 Stiffness of unspecified wrist, not elsewhere classified M24.541 Contracture, right hand M24.542 Contracture, left hand M24.549 Contracture, unspecified hand M25.641 Stiffness of right hand, not elsewhere classified M25.642 Stiffness of left hand, not elsewhere classified M25.649 Stiffness of unspecified hand, not elsewhere classified

The above medical necessity criteria MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue, and Medicare PPO Blue: HCPCS codes:

Code Description E1810 Dynamic adjustable knee extension and flexion device, includes soft interface material E1813 Dynamic adjustable knee extension only device, includes soft interface material E1814 Dynamic adjustable knee flexion only device, includes soft interface material E1812 Dynamic knee, extension/flexion device with active resistance control

The following ICD Diagnosis Codes are considered medically necessary when submitted with the CPT codes above if medical necessity criteria are met: ICD-10-CM diagnosis codes: Code Description M24.561 Contracture, right knee M24.562 Contracture, left knee M24.569 Contracture, unspecified knee M25.661 Stiffness of right knee, not elsewhere classified M25.662 Stiffness of left knee, not elsewhere classified

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M25.669 Stiffness of unspecified knee, not elsewhere classified

The following HCPCS codes are considered investigational for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue:

HCPCS Codes HCPCS codes:

Code Description E1815 Dynamic adjustable ankle extension and flexion device, includes soft interface material E1822 Dynamic adjustable ankle extension only device, includes soft interface material E1823 Dynamic adjustable ankle 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 E1830 Dynamic adjustable toe extension and flexion device, includes soft interface material E1840 Dynamic adjustable shoulder flexion/abduction/rotation device, includes soft interface material Description Loss of or reduced range of motion (ROM) in individuals can occur following surgery, traumatic injury, or disease. Lengthy immobilization of the affected joint can lead to joint contractures and the development of intra-articular or extra-articular arthrofibrosis. Arthrofibrosis is characterized by periarticular fibrosis and bands of scar tissue. The elastic connective tissue is replaced with fibrous material that is resistant to stretching and results in reduced ROM. This can lead to impairments in activities of daily living, including, walking, sitting, and reaching. Treatment options for loss of range of motion include several different modalities including physical therapy, occupational therapy, manipulation under anesthesia, surgical release, lysis of adhesions, revision surgery, or mechanical devices. Conservative treatment typically consists of postoperative physical therapy with pressure stretching techniques and home exercises. When rehabilitation has failed, serial casting, static braces, or dynamic splints that provide low-load prolonged stretch may be used.
Dynamic low-load prolonged-duration stretch (LLPS) devices are splinting devices that use spring tension at set levels to apply a constant gentle stretch to stiff tissues. The objective of the dynamic LLPS device is to restore range of motion to the joint without compromising the stability and quality of the connective tissue and the joint itself. Dynamic LLPS devices are set at a fixed joint angle and designed to be worn over long periods, approximately 6-8 hours, while an individual is at rest or sleeping. These devices provide extension as well as flexion. Dynamic LLPS devices are often used during the post-operative period for prevention or treatment of decreased ROM in the knee, elbow, wrist, or finger. Examples of dynamic LLPS devices include, but are not limited to Dynasplint® systems, JAS® Advance Dynamic systems (Joint Active Systems), Ultraflex® systems, and Pro-Glide™ systems.
Summary Rives and colleagues (1992) reported the results of a prospective, non-randomized study of operative correction and dynamic splinting of 23 interphalangeal joints contracted due to Dupuytren’s disease. The proximal interphalangeal joints were contracted at an angle greater than or equal to 45 degrees. After the contractures were corrected operatively, dynamic extension splinting was used for a total of 6 months. Proximal interphalangeal joint extension was measured pre and postoperatively at 3-month intervals for 1 year. After the first year the joints were measured at 6-month intervals thereafter. Mean follow-up was 2 years (minimum, 1 year). Overall, at 2 years, 44% improvement in proximal interphalangeal joint extension was noted. In participants who complied with the postoperative dynamic extension splinting program a mean improvement of 59% in proximal interphalangeal joint extension was noted. A 25% improvement in proximal interphalangeal joint extension was noted in participants who were noncompliant. There was a statistically significant difference between participants who were compliant and those who were not. Factors such as the severity of contracture, the digit involved, and the necessity

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for capsular release were not significantly related to outcome. The authors concluded that soft tissue responds to continuous dynamic extension stresses and can be remodeled over time. A retrospective study performed by Nuismer and colleagues (1997) examined the use of LLPS orthoses for contracture management. The records of 17 individuals with 18 contractures (2 wrist, 12 elbows, 4 knees) using LLPS orthoses were analyzed. Participant demographic information, ROM, functional outcomes, and the scheduled usage of the device were the focus of the review. The authors found that the use of LLPS orthoses significantly increased ROM for the whole sample. This significantly improved the participants' functional outcomes. The sample was then divided into two pathology groups to compare outcomes. One group was a predominately geriatric population with neurological pathologies and the other a younger population with a history of musculoskeletal pathology. Both groups showed a significant gain in ROM with the use of the LLPS orthoses. The authors concluded that the use of LLPS orthoses for contracture management can mediate the losses in ROM and function that occur with joint contractures. Lindenhovius and colleagues (2012) conducted a prospective randomized controlled trial to compare the use of dynamic and static progressive (turnbuckle) splints in stretching a contracted elbow capsule in order to regain motion after elbow trauma. The authors tested the null hypothesis that there is no difference between static progressive and dynamic splinting in improvement of motion and Disabilities of the Arm, Shoulder and Hand (DASH) scores. A total of 66 subjects with posttraumatic elbow stiffness were enrolled in the trial: 35 in the static progressive and 31 in the dynamic cohort. Elbow function was measured at enrollment and then at 3, 6, and 12 months later. The DASH questionnaire was completed at enrollment and at the six and twelve month evaluation. A total of 3 participants requested to be switched to static progressive splinting. There were no significant differences in flexion arc at any time point during the evaluations. Improvement in the arc of flexion (dynamic versus static) averaged 29 degrees versus 28 degrees at 3 months (p=0.87), 40 degrees versus 39 degrees at 6 months (p=0.72), and 47 degrees versus 49 degrees at 12 months after splinting was initiated (p=0.71). The average DASH score (dynamic versus static) was 50 versus 45 points at enrollment (p=0.52), 32 versus 25 points at 6 months (p<0.05), and 28 versus 26 points at 12 months after enrollment (p=0.61). The authors concluded that posttraumatic elbow stiffness can improve with exercises and dynamic or static splinting over a period of 6 to 12 months, and patience is warranted. There were no significant differences in improvement in motion between static progressive and dynamic splinting protocols. Glasgow et. al. (2012) examined the long-term relationship between dynamic orthoses and contracture resolution, in both flexion and extension deficits of the stiff proximal interphalangeal (PIP) joint. Forty-one participants were treated with a dynamic orthotic device (splint) for either a flexion or extension deficit of the PIP joint. There was a total of 48 joints treated. The relationship between contracture resolution and weeks of treatment was examined. Outcome was measured via change in torque and active ROM. The authors found that ROM increased in a linear fashion. Faster progress was observed when treatment was aimed at improving flexion rather than extension. Flexion deficits appeared to maximize gains with orthotic treatment after 12 weeks. However, extension deficits continued to demonstrate slow and continuous improvement beyond the 17 weeks of recorded data. Less treatment duration (in weeks) was needed to restore flexion than extension. The authors concluded that the duration of orthotic use is significantly associated with the extent of contracture resolution. Slower recovery of ROM and a longer duration of orthotic use may be expected when the treatment goal is to improve extension rather than flexion.
A systematic review was performed by Furia et al. (2013) to evaluate the safety and efficacy of dynamic splinting as it is used to treat joint contracture in lower extremities, and to determine if duration on total hours of stretching had an effect on outcomes. A total of 354 abstracts were screened and 8 studies with 487 subjects met the inclusion criteria. The primary outcome measure was change in active ROM (AROM). The mean aggregate change in AROM was 23.5º in the collective studies. Dynamic splinting with prolonged, passive stretching as home therapy treatment showed a significant direct, linear correlation between the total number of hours in stretching and restored AROM. The authors concluded that dynamic splinting is a safe and efficacious treatment for lower extremity joint contractures. Another systematic review was conducted by Veltman et. al. (2015) to evaluate the best current evidence for nonoperative treatment options for posttraumatic elbow stiffness. A search was performed of all studies on nonoperative treatment for elbow stiffness in adults. Eight studies (one RCT and seven

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retrospective cohort studies) met the eligibility criteria and were included for data analysis and pooling. A total of 232 patients were included in the review. Static progressive splinting was evaluated in 160 patients. The average pre-splinting range of motion of all elbows was 72°, which improved by 36° after splinting to an average post-splinting arc of motion of 108°. Dynamic splinting was evaluated in 72 patients with an average pre-splinting range of motion of 63°. The average improvement was 37° to an average post-splinting arc of motion of 100°. The authors concluded that both dynamic splinting and static progressive splinting were effective in treating elbow stiffness.
Although there is limited evidence from well-designed clinical trials on the use of dynamic LLPS devices, this technology is frequently employed as a component of rehabilitation of fingers, wrists, elbows, and knees in the postoperative period. On the basis of national community standards, dynamic splinting may be considered eligible for coverage with criteria in the clinical settings outlined under the coverage section of this document. Policy History Date Action 1/2025 Clarified coding information.
8/2024 New medical policy describing medically necessary and investigational indications. Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines References

1. Furia JP, Willis FB, Shanmugam R, Curran SA. Systematic review of contracture reduction in the lower extremity with dynamic splinting. Adv Ther. 2013 Aug;30(8):763-70. doi: 10.1007/s12325-013- 0052-1. Epub 2013 Sep 10. PMID: 24018464; PMCID: PMC3779086.
2. 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-Mar;25(1):38-46; quiz 47. doi: 10.1016/j.jht.2011.09.006. Epub 2011 Dec 1. PMID: 22133663.
3. 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.
4. Hepburn GR. Case studies: contracture and stiff joint management with Dynasplint. J Orthop Sports Phys Ther. 1987; 8(10):498-504.
5. Lindenhovius AL, Doornberg JN, Brouwer KM, et al. A prospective randomized controlled trial of dynamic versus static progressive elbow splinting for posttraumatic elbow stiffness. J Bone Joint Surg Am. 2012; 94(8):694-700. https://pubmed.ncbi.nlm.nih.gov/22517385/
6. MacKay-Lyons M. Low-load, prolonged stretch in treatment of elbow flexion contractures secondary to head trauma: a case report. Phys Ther. 1989; 69(4):292-296.
7. Nuismer BA, Ekes AM, Holm MB. The use of low-load prolonged stretch devices in rehabilitation programs in the Pacific Northwest. Am J Occup Ther. 1997; 51(7):538-543. https://pubmed.ncbi.nlm.nih.gov/9242860/
8. Richard RL, Jones LM, Miller SF, Finley RK Jr. Treatment of exposed bilateral Achilles tendons with use of the Dynasplint. A case report. Phys Ther. 1988; 68(6):989-991.
9. Rives K, Gelberman R, Smith B, Carney K. Severe contractures of the proximal interphalangeal joint in Dupuytren's disease: results of a prospective trial of operative correction and dynamic extension splinting. J Hand Surg. 1992; 17(6):1153-1159.
10. Steffen TM, Mollinger LA. Low-load, prolonged stretch in the treatment of knee flexion contractures in nursing home residents. Phys Ther. 1995; 75(10):886-895. https://pubmed.ncbi.nlm.nih.gov/7568388/
11. Veltman ES, Doornberg JN, Eygendaal D, van den Bekerom MP. Static progressive versus dynamic splinting for posttraumatic elbow stiffness: a systematic review of 232 patients. Arch Orthop Trauma

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Surg. 2015 May;135(5):613-7. doi: 10.1007/s00402-015-2199-5. Epub 2015 Mar 13. PMID:

25764510. Endnote

          1 Based on expert opinion