Criteria
Dynamic low-load prolonged-duration stretch (LLPS) devices for the toe, knee, elbow, wrist, or finger may be considered medically necessary in any of the following clinical settings:
- As an addition to physical therapy in the subacute injury or post-operative period (greater than or equal to three (3) weeks, but less than or equal to four (4) months after injury or operation) in individuals with signs and symptoms of persistent joint stiffness or contracture:
- For an initial period of up to four (4) months; and
- If the individual shows improvement after the initial period, thereafter for as long as improvement can continue to be demonstrated; or
- In the subacute injury or post-operative period (greater than or equal to three (3) weeks, but less than or equal to four (4) months after injury or operation) in an individual whose limited range of motion poses a meaningful (as judged by the physician) functional limitation, and who has not responded to other therapy (including physical therapy);
- For an initial period of up to four (4) months; and
- If the individual shows improvement after the initial period, thereafter for as long as improvement can continue to be demonstrated; or
- In the acute post-operative period for individuals who have undergone additional surgery to improve the range of motion of a previously affected joint:
- For an initial period of up to four (4) months; and
- If the individual shows improvement after the initial period, thereafter for as long as improvement can continue to be demonstrated; or
- For individuals unable to benefit from standard physical therapy modalities because of an inability to exercise:
- For an initial period of up to four (4) months; and
- If the individual shows improvement after the initial period, thereafter for as long as improvement can continue to be demonstrated.
Replacement of soft interface material for dynamic adjustable extension/flexion devices may be considered medically necessary per coverage criteria.
If there is no significant improvement after four four (4) months of use, dynamic (LLPS) devices for the toe, knee, elbow, wrist, or finger are considered not medically necessary under any circumstance including, but not limited to, for individuals unable to benefit from standard physical therapy modalities because of an inability to exercise.
Dynamic low-load prolonged-duration stretch (LLPS) devices used for all other conditions are considered not medically necessary.