Subject:
Dynamic Splinting Devices
Description:
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IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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There are several types of mechanical stretching devices that have been developed to restore functioning range of motion to a joint with stiffness and limited range of motion.
A. Dynamic Splinting Devices – these are spring-loaded low load prolonged stretch devices that apply continuous stretch to the affected joint. The patient may adjust the tension of the spring but otherwise no patient intervention is required. Examples include the Dynasplint, Ultraflex, LMB Pro-Glide and EMPI Advance.
B. Flexionators and Extensionators – these are patient-controlled bi-directional static progressive stretch devices intended to provide alternating stretching and relaxation of the affected joint. Examples include the ERMI Shoulder Flexionater, ERMI Elbow Extensionater, and ERMI Knee/Ankle Flexionater. Also included in this category are the pronator/supinator devices.
C. Joint Active System (JAS) Splints – these devices apply static progressive stretch in which the patient manually increases the angle to which the device applies to the affected joint. Examples include the JAS Shoulder, JAS Elbow, and JAS Knee.
Related Policies:
- Patient-Controlled End Range of Motion Stretching Devices (Policy #046 in the DME Section)
Policy:
(NOTE: For Flexionators/Extensionators and Joint Active System or JAS splints, please refer to a separate policy on 'Patient-Controlled End Range of Motion Stretching Devices' Policy #046 in the DME Section.
For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)
1. Dynamic splinting devices are considered medically necessary for use on the knee, elbow, forearm, wrist, finger, shoulder, ankle or toe in any of the following situations:
a. as adjunct to physical therapy in the sub-acute 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 members with signs and symptoms of persistent joint stiffness;
b. in the acute post-operative period for members who are undergoing additional surgery to improve the range of motion of a previously affected joint;
c. for members who are unable to benefit from standard physical therapy modalities because of inability to exercise. If there is no significant change in range of motion after a 4-month period, use of the device is considered as maintenance and thus, not medically necessary and appropriate.
[INFORMATIONAL NOTE: Although there is inadequate data published in the peer reviewed medical literature regarding the effectiveness of dynamic splinting devices in improving range of motion, this type of device has been widely used in the orthopedic and physical therapy communities for select patient population. It is on the basis of national community standards that the use of dynamic splinting devices in specific clinical situations (as indicated in the policy statement above) is considered reasonable and medically appropriate.]
2. Dynamic splinting devices are also considered medically necessary in conjunction with botulinum toxin injections and physical therapy, for the management of orthopedic conditions with associated joint contractures and neurologic disorders with associated spasticity and contractures (e.g., post-CVA, traumatic brain injury).
3. Use of dynamic splinting devices for joints and/or situations other than those indicated above, and in the management of chronic joint stiffness and/or chronic or fixed contractures, is considered investigational.
Medicare Coverage:
There is no National Coverage Determination (NCD). In the absence of an NCD, coverage decisions are left to the discretion of Local Medicare Carriers. Noridian Healthcare Solutions, LLC, the Local Medicare Carrier for jurisdiction JA, has not issued a determination for this service. Therefore, Medicare Advantage Products will follow the Horizon BCBSNJ Medical Policy.
Medicaid Coverage:
For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.
FIDE SNP:
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.
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Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
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Index:
Dynamic Splinting Devices
Dynasplint Devices
Treatment of Joint Stiffness and Contracture with Mechanical Stretching Devices
Ultraflex
LMB Pro-Glide
EMPI Advance
References:
1. ECRI Institute. Health Technology Assessment Information Service (HTAIS) Hotline Response: Mechanical Stretching Devices (ERMI Flexionaters and Extensionaters) for Contracture and Joint Stiffness. Updated 03/30/2009 (last accessed 06/09/2009).
2. ECR Institute. Health Technology Assessment Information Service (HTAIS) Hotline Response: Joint Active Systems (JAS) Devices for Improving Range of Motion in Injured Joints. Updated 10/12/2007 (last accessed 2/6/08).
3. Brashear A, Gordon MF, Elovic E, et al. Intramuscular injection of botulinum toxin for the treatment of wrist and finger spasticity after stroke. N Engl J Med 2002;347:395-400.
4. Ozcakir S, Sivrioglu K. Botulinum toxin in poststroke spasticity. Clinical Medicine & Research 2007;5(2):132-138.
5. Shah MA, Lopez JK, Escalante AS, et al. Dynamic Splinting of Forearm Rotational Contracture After Distal Radius Fracture. J Hand Surg 2002;27A:456-463.
6. Kimbler TS, Willis FB. Dynamic splinting for pronation contracture following a spinal cord injury. Hand Therapy 2010 Mar;15(1):20-22.
7. Furia JP, Willis FB, Shanmugam R, et al. Systematic review of contracture reduction in the lower extremity with dynamic splinting. Adv Ther. 2013 Aug;30(8):763-70.
8. 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 May;135(5):613-7.
Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)
CPT*
HCPCS
E1800
E1802
E1805
E1810
E1812
E1815
E1820
E1821
E1825
E1830
E1840
* CPT only copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
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