Dynamic Splinting for the Treatment of Joint Stiffness and Contracture, Treatment of Joint Stiffness

Version 3.0 Johns Hopkins HealthCare LLC Policy Number CMS19.07 Medical Policy Effective Date 05/01/2020 Medical Policy Review Date 02/18/2020

Subject Revision Date 02/18/2020 Dynamic Splinting for the Treatment of Joint Stiffness and Page 1 of 7 Contracture

This document applies to the following Participating Organizations: EHP Johns Hopkins Advantage MD Priority Partners US Family Health Plan

Keywords: Contracture, Dynamic Splinting, Dynamic Splinting for the Treatment of Joint Stiffness and Contracture, Treatment of Joint Stiffness

Table of Contents Page Number I. ACTION 1 II. POLICY DISCLAIMER 1 III. POLICY 1 IV. POLICY CRITERIA 2 V. BACKGROUND 3 VI. CODING DISCLAIMER 3 VII. CODING INFORMATION 3 VIII. REFERENCE STATEMENT 5 IX. REFERENCES 6 X. APPROVALS 7

I. ACTION New Policy X Revising Policy Number CMS19.07 Superseding Policy Number Archiving Policy Number Retiring Policy Number

II. POLICY DISCLAIMER Johns Hopkins HealthCare LLC (JHHC) provides a full spectrum of health care products and services for Employer Health Programs, Priority Partners, Advantage MD and US Family Health Plan. Each line of business possesses its own unique contract and guidelines which, for benefit and payment purposes, should be consulted first to know what benefits are available for coverage.

Specific contract benefits, guidelines or policies supersede the information outlined in this policy.

III. POLICY For Advantage MD, refer to: Medicare Coverage Database

• Local Coverage Determination (LCD) L33686 Ankle-Foot/Knee-Ankle-Foot Orthosis

For Employer Health Programs (EHP) refer to:

© Copyright 2020 by The Johns Hopkins Health System Corporation and/or The Johns Hopkins University Version 3.0 Johns Hopkins HealthCare LLC Policy Number CMS19.07 Medical Policy Effective Date 05/01/2020 Medical Policy Review Date 02/18/2020

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• Plan specific Summary Plan Descriptions

For Priority Partners (PPMCO) refer to: Code of Maryland Regulations

• Code of Maryland Regulations (COMAR) 10.67.06.13 Benefits - Disposable Medical Supplies and Durable Medical Equipment

For US Family Health Plan (USFHP) refer to: Tricare Policy Manuals

• TRICARE Policy Manual 6010.60-M, April 1, 2015 Chapter 8, Section 2.1 Durable Equipment (DE): Basic Program

IV. POLICY CRITERIA A. When benefits are provided under the member’s contract, JHHC considers dynamic splinting devices for use on the knee, elbow, wrist or finger medically necessary durable medical equipment when one of the two following conditions are met: 1. As an adjunct to physical therapy in the sub-acute injury or post-operative period (> 3 weeks but < 4 months after injury or operation) in patients with signs and symptoms of persistent joint stiffness, OR; 2. In the acute post-operative period for patients who are undergoing additional surgery to improve the range of motion of a previously affected joint. B. Unless specific benefits are provided under the member’s contract, JHHC considers the following experimental and investigational as they do not meet Technology Evaluation Criteria (TEC) : 1. Dynamic splinting for the following: a. The management of chronic joint stiffness and/or chronic or fixed contractures. b. For use in shoulders or any other condition not listed above. c. For prophylactic use. d. For continued use if no significant improvement in range of motion after 4 (four) months of use. 2. Bi-directional static progressive stretch splinting, Joint Active Systems and Flexionators/Extensionators. 3. Use of dynamic splinting for the following medical indications: a. Carpal tunnel syndrome b. Cerebral Palsy c. Foot drop secondary to neuromuscular disease d. Head and spinal cord injuries e. Injuries of the ankle and shoulder f. Multiple sclerosis g. Muscular dystrophy h. Plantar fasciitis i. Rheumatoid arthritis j. Stroke k. Trismus l. Hallux Valgus C. Requests for continued dynamic splinting beyond 4 months or for any conditions listed in A above may receive individual consideration when accompanied by medical records, a plan of care and supporting peer-reviewed medical literature.

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V. BACKGROUND Spring loaded dynamic splints and bi-directional static progressive stretch splints are intended to stretch joints that have reduced range of motion secondary to immobilization, surgery, contracture, fracture, dislocation, or a number of additional non traumatic disorders. The goal is to cause permanent elongation of the connective tissue in order to increase range of motion. Most dynamic splinting devices are adjustable-tension controlled units designed to provide a low load, prolonged stretch to joints used commonly while patients are asleep or at rest for 6 to 12 hours. The Dynasplint® Systems and other splinting systems have been developed for the treatment of stiffness and contractures for many joints. The strength of peer reviewed scientific evidence supporting the use of these devices varies by medical condition, joint and device.

A static progressive stretch device applies a different biomechanical principle than dynamic splinting devices. Static progressive stretch devices are used typically 30 minutes, 2 to 3 times per day. These technologies are widely used by the Orthopedic and Physical Therapy communities for selected patient populations.

Note:The following CPT/HCPCS codes are included below for informational purposes and may not be all inclusive. Inclusion or exclusion of a CPT/HCPCS code(s) below does not signify or imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member’s specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee of payment. Other policies and coverage determination guidelines may apply.

Note: All inpatient admissions require pre-authorization.

Compliance with the provision in this policy may be monitored and addressed through post payment data analysis and/or medical review audits Employer Health Programs Priority Partners (PPMCO) US Family Health Plan Advantage MD, LCD (EHP) refer to specific refer to COMAR guidelines (USFHP), TRICARE and NCD Medical Policy Summary Plan Description then apply the Medical Medical Policy supersedes supersedes JHHC Medical (SPD). If there is no criteria Policy criteria. JHHC Medical Policy. Policy. If there is no LCD in the SPD, apply the If there is no Policy in or NCD, apply the Medical Medical Policy criteria. TRICARE, apply the Policy Criteria. Medical Policy Criteria.

VII. CODING INFORMATION HCPCS DESCRIPTION CODES E1800 Dynamic adjustable elbow extension/flexion device, includes soft interface material E1801 Static progressive stretch elbow device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories

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E1802 Dynamic adjustable forearm pronation/supination device, includes soft interface material E1805 Dynamic adjustable wrist extension/flexion device, includes soft interface material E1806 Static progressive stretch wrist device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories E1810 Dynamic adjustable knee extension/flexion device, includes soft interface material E1811 Static progressive stretch knee device, extension, and/or flexion, with or without range of motion adjustment, includes all components and accessories E1812 Dynamic knee, extension/flexion device with active resistance control E1815 Dynamic adjustable ankle extension/flexion device, includes soft interface material E1816 Static progressive stretch ankle device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories E1818 Static progressive stretch of forearm pronation/supination device, with or without range of motion adjustment, includes all components and accessories E1820 Replacement soft interface material, dynamic adjustable extension/flexion device E1821 Replacement soft interface material/cuffs for bi-directional static progressive stretch device E1825 Dynamic adjustable finger extension/flexion device, includes soft interface material E1830 Dynamic adjustable toe extension/flexion device, includes soft interface material E1831 Static progressive stretch toe device extension and/or flexion, with or without range of motion adjustment, includes all components or accessories E1840 Dynamic adjustable shoulder flexion/abduction/rotation device, includes soft interface material E1841 Static progressive stretch shoulder device, with or without range of motion adjustment, includes all components and accessories

ICD10 DESCRIPTION CODES G35 Multiple sclerosis G56.00-G56.03 Carpal tunnel syndrome G80.0-G80.9 Cerebral palsy I63.00-I66.9 Occlusion and stenosis of precerebral arteries [stroke]

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M05.00- Rheumatoid arthritis w/rheumatoid factor, other rheumatoid arthritis M05.09, M05.20- M06.39, M06.80-M06.9, M08.20-M08.3, M08.40- M08.99 M20.10- Hallux valgus M20.12 M21.371- Foot drop (acquired) [foot drop associated with neuromuscular diseases] M21.379 M72.2 Plantar fascial fibromatosis [plantar fascitits] R25.2 Cramp and spasm [trismus] S06.0x0+- Intracranial injury S06.9x9+ S09.90x+ Unspecified injury of head S12.000+- Fracture of vertebral column with spinal cord injury S12.9xx+, S14.010+- S14.159+ S22.000+- S22.089+, S24.101+- S24.159+, S32.000+- S32.2xx+, S34.101+- S34.13+, S34.3xx+ S52.121A- Fracture of head of radius S52.126S

VIII. REFERENCE STATEMENT Analyses of the scientific and clinical references cited below were conducted and utilized by the Johns Hopkins HealthCare LLC (JHHC) Medical Policy Team during the development and implementation of this medical policy. The Medical Policy Team will continue to monitor and review any newly published clinical evidence and revise the policy and adjust the references below accordingly if deemed necessary.

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IX. REFERENCES Aetna. ( 2019). Clinical Policy Bulletin: Mechanical Stretching Devices for Contracture and Joint Stiffness. Medical Policy Number: 0405. Retrieved: http://www.aetna.com

Berner, SH & Willis FB. (2010). Dynamic Splinting in Wrist Extension Following Distal Radius Fractures. Journal of Orthopaedic Surgery and Research, 5(53).

Branch, T.P., Karsch, R.E., Mills, et al. (2003). Mechanical therapy for loss of knee flexion. Am J Orthop (Belle Mead NJ), 32(4), 195-200.

Farmer, S.E., Woollam, P.J., Patrick, J.H., et al. (2005). Dynamic Orthoses in the Management of Joint Contracture. J Bone Joint Surg Br, 87(3), 291-295.

Ferrari, J., Eiff, P., Asplund, C.A., (2017). Hallux valgus deformity (bunion). UpToDate. Retrieved:https://www.uptodate.com/ contents/hallux-valgus-deformity-bunion

Furia J P, Willis F B, Shanmugam R, et al. (2013). Systemic Review of Contracture Reduction in the Lower Extremity w/ Dynamic Splinting. Advances in Therapy, 30(8), 763-770.

Gaspar, P.D., Willis, F.B., (2009). Adhesive Capsulitis and Dynamic Splinting; A Controlled, Cohort Study. BMC Musculoskeletal Disorders, Article number: 111. Retrieved: https://bmcmusculoskeletdisord.biomedcentral.com/ articles/10.1186/1471-2474-10-111

Glasgow C, Tooth LR, Fleming J, et al. Dynamic Splinting for the Stiff Hand after Trauma: Predictors of Contracture Resolution. Journal of Hand Therapy, 24(3), 195-206.

Hayes, Inc. (2016). Medical Technology Directory Center: Mechanical Stretching Devices for the Treatment of Joint Contractures of the Extremities. Retrieved: https://www.hayesinc.com/

Lundequam, P., Willis, F.B. (2009). Dynamic splinting home therapy for toe walking: a case report. Cases J, 2, 188.

Plaass,C., Karch, A., Koch, A., et al. (2020). Short term results of dynamic splinting for hallux valgus- A prospective randomized study. Foot Ankle Surg. Retrieved: https://www.ncbi.nlm.nih.gov/pubmed/30718168

U.S. Food and Drug Administration (FDA). (2017). Mechanical Stretching Devices are classified by the FDA as Class I medical devices. Retrieved: http://www.fda.gov

United Healthcare. (2017). Medical Policy: Mechanical Stretching and Continuous Passive Motion Devices. Medical Policy Number 2017T0481N. Retrieved: https://www.unitedhealthcareonline.com

United Healthcare. (2019). Medical Policy: Mechanical Stretching Devices. Medical Policy Number: 2019T0481Q. Retrieved:file:///C:/Users/skelly/Downloads/mechanical-stretching-devices%20(2).pdf

Veltman ES, Doornberg JN, Eygendaal D, et al. (2015). Static Progressive versus Dynamic Splinting for Posttraumatic Elbow Stiffness: A Systematic Review of 232 Patients. Archives of Orthopaedic and Trauma Surgery, 135(5),613-617.

Willis, F.B., Fowler, B., (2016). Longitudinal Outcomes Following a Randomized Controlled Trial of Dynamic Splint Stretching of Carpal Tunnel Syndrome. HAND. 11(3), 290-294. Retrieved: https://www.ncbi.nlm.nih.gov/pubmed/27698630

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Zhang, L.Q., Chung, S.G., Bai, Z., et al. (2002). Intelligent Stretching of Ankle Joints Contracture/Spasticity. IEEE Trans Neural Syst Rehabil Eng,10(3), 149-57.

X. APPROVALS Historical Effective Dates: 10/21/2006, 06/25/2008, 06/04/2009, 04/02/2010, 01/07/2011, 12/06/2013, 09/04/2015, 09/01/2017, 10/01/2019, 05/01/2020