HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
O-10-014
Topic:
Dynamic Splinting Devices
Section:
Orthotic & Prosthetic Devices
Effective Date:
March 18, 2019
Issued Date:
March 18, 2019
Last Revision Date:
June 2017
Annual Review:
January 2019
 
 

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.

Policy Position

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 as long 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.

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

E1399

E1801

E1806

E1811

E1815

E1816

E1818

E1821

E1831

E1840

E1841

L3999

 

 




Place of Service: Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

The use of a dynamic splinting device is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.


The policy position applies to all commercial lines of business



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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

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