Dynamic splinting devices (include but not limited to: Dynasplint Systems, LMB Pro-glide, EMPI Advance, Ultraflex, and Advanced Bio Mechanics), is considered medically necessary for use on the knee, elbow, wrist or finger in any of the following clinical settings:

1. As an addition 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.
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.
3. For patients unable to benefit from standard physical therapy modalities because of an inability to exercise. No significant change after four months period is prophylactic use in contractures and is not medically necessary.

Investigational/Not Medically Necessary:                                

1. Dynamic splinting is considered investigational/not medically necessary for use in the management of chronic joint stiffness and/or chronic or fixed contractures.
2. For use in shoulders or any other condition not listed above dynamic splinting is considered investigational/not medically necessary.
3. Bi-directional static progressive stretch splinting (include but not limited to: Joint Active Systems (JAS splints) & Air Cast) is considered investigational/not medically necessary.

Most spring loaded dynamic splinting devices are designed to provide a low load, prolonged stretch to joints that have reduced range of motion secondary to immobilization, surgery, contracture, fracture, dislocation, or a number of additional non-traumatic disorders. Most of these devices are adjustable-tension controlled units that provide a continuous dynamic stretch while patients are asleep or at rest. Commonly time of use is continuously for 6 – 12 hours, which can be at night or can be two three-hour sessions during the day.  Medically necessary wearing time is less than four months. The objective of stretch therapy is to improve range of motion without compromising the stability and quality of the connective tissue and joint. Currently, dynamic splinting devices are available for but not limited to the elbow, wrist, knee, ankle, and toes.  For use in shoulders or any other condition not listed above as medically necessary, there is a lack of scientific evidence regarding its effectiveness. 

Bidirectional static progressive stretch devices concept of static progressive stretching applies a different biomechanical principle than the medical necessity criteria mentioned for the spring loaded dynamic splinting devices of low load prolonged stress technique.  The static progressive stretch technique, coupled with stress relaxation, a series of incremental increasing displacements is applied to a joint over a period of time, which theoretically causes plastic deformation of the soft tissues, which the brace can maintain.  The stretch or force applied is typically increased every few minutes by the patient in order to increase range of motion during the period of brace utilization, thus the area never has time to recover.  The period of brace utilization is typically 30 minutes, used 2-3 times a day.  The combined principles of static progressive stretch & stress relaxation are utilized in braces from manufacturers that include but may not be limited to: Joint Active Systems (JAS splints) & Air Cast.

There is currently no definitive CPT code for dynamic splinting.  However, it is possible that providers may bill for the device using the following procedure and diagnosis code(s):

HCPCS

ICD-9 Diagnosis

When services are Investigational/Not Medically Necessary:

For the procedure codes listed above, for all other diagnoses not listed, when criteria are not met; or when the code describes a procedure indicated in the Policy section as Investigational/Not Medically Necessary.

When services are also Investigational/Not Medically Necessary:

HCPCS

ICD-9 Diagnosis

Mountain State Blue Cross Blue Shield of Wisconsin