Dynamic Splinting Devices

Effective Date: July 01, 2018
Revised Date: August 13, 2019
Last Reviewed: July 16, 2019

Description

Dynamic splinting devices are spring-loaded and designed to provide a low load, prolonged stretch (LLPS) to joints that have reduced range of motion secondary to immobilization, surgery, contracture, fracture, dislocation, or a number of additional non-traumatic disorders.

Bi-directional static progressive (SP) stretch devices are used for multiple short treatment sessions per day with the joint angle progressively advanced at each session.Patient-actuated serial stretch (PASS) devices provide a low-to-high level load to the joint using pneumatic or hydraulic systems that are adjusted by the patient.

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 3 weeks, but less than or equal to 4 months after injury or operation) in patients with signs and symptoms of persistent joint stiffness or contracture:
    • For an initial period of up to 4 months; and
    • If the patient shows improvement after the initial period, thereafter for a slong as improvement can continue to be demonstrated; or
  • In the subacute injury or post-operative period (greater than or equal to 3 weeks, but less than or equal to 4 months after injury or operation) in a patient 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 4 months; and
    • If the patient 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 patients who have undergone additional surgery to improve the range of motion of a previously affected joint:
    • For an initial period of up to 4 months; and
    • If the patient shows improvement after the initial period, thereafter for as long as improvement can continue to be demonstrated; or
  • For patients unable to benefit from standard physical therapy modalities because of an inability to exercise:
    • For an initial period of up to 4 months; and
    • If the patient 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 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 patients 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.

Procedure Codes

E1800  E1802 E1805 E1810 E1812
E1820 E1825 E1830

The following devices are considered experimental/investigational. There is a lack of scientific evidence supporting the effectiveness of these devices.

  • Dynamic (LLPS) devices which are specific to the ankle and shoulder
  • SaeboFlex
  • Bi-directional static progressive (SP) stretch devices
  • Replacement of soft interface material for bi-directional static progressive (SP) stretch devices
  • Patient-actuated serial stretch (PASS) devices

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

  • Carpal tunnel syndrome
  • Cerebral palsy
  • Foot-drop associated with neuromuscular diseases
  • Head and spinal cord injuries
  • Injuries of the ankle and shoulder
  • Multiple sclerosis
  • Muscular dystrophy
  • Plantar fasciitis
  • Rheumatoid arthritis
  • Stroke
  • Trismus

Procedure Codes

E1399 E1801 E1806 E1811 E1815
E1816 E1818 E1821 E1831 E1840
E1841 L3999

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