Print

Date Printed: October 20, 2017: 12:01 PM

Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

09-E0000-47

Original Effective Date: 12/15/03

Reviewed: 03/26/15

Revised: 11/01/15

Subject: Mechanical Stretching Devices for Treatment of Joint Stiffness and Contractures

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates  
           

DESCRIPTION:

Physical and occupational therapy are used to improve or restore range of motion (ROM) by manually stretching contracted ligaments, tendons and tissue when abnormal tightening has occurred. This may be brought about by injury, disease or surgery. There are also mechanical stretching devices that can assist in restoring or improving ROM and may be rented or purchased for use at home, as an adjunct to the therapy. The devices are also used post-operatively when surgery has been performed for certain conditions but these devices are not continuous passive motion (CPM) machines. CPM machines are used just after a surgery or injury to improve healing, reduce edema & pain, and to help prevent contractures.

Mechanical stretching devices, also known as dynamic splinting devices, are spring-loaded, adjustable, and designed to provide low-load prolonged stretch while patients are asleep or at rest. These devices (for both extension as well as flexion) are available and are marketed for the treatment of joint stiffness due to immobilization or limited ROM. Several types of mechanical stretching devices are available including:

Currently, several FDA approved commercial stretching devices are available but there is no evidence that one type of device is superior over others.

POSITION STATEMENT:

 

Certificate of Medical Necessity

Submit a completed Certificate of Medical Necessity (CMN) along with your request to expedite the medical review process.

1. Click the link Mechanical Stretching Devices - Certificate of Medical Necessity (MS Word) to open the form.

2. Complete all fields on the form thoroughly.

3. Print and submit a copy of the form with your request.

Note: Florida Blue regularly updates CMNs. Ensure you are using the most current copy of a CMN before submitting to Florida Blue. For a complete list of available CMNs, visit the Certificates of Medical Necessity page.

Dynamic (LLPS) devices meet the definition of medical necessity for use on the toe, knee, elbow, wrist or finger for ONE of the following indications:

  1. As an adjunct to physical therapy in members with documented signs and symptoms of significant motion stiffness/loss in the sub-acute injury or post-operative period (i.e., at least three (3) weeks but less than four (4) months after injury or surgery); OR
  2. In the acute post-operative period for members who have a prior documented history of motion stiffness/loss in a joint and are having additional surgery or procedures done to improve motion to that joint; OR
  3. The member is unable to perform and/or benefit from standard physical therapy modalities because of an inability to exercise or participate in the treatment program. In this instance, use of a dynamic device for as long as four (4) months with documented improvement, and then for as long as improvement can continue to be documented would be considered medically necessary.

If there is no significant improvement (i.e. documentation of progression toward goals, increased range of motion, advancing ability to perform activities of daily living (ADLs) or return to prior ability to perform ADLs) after four (4) months of use, dynamic (LLPS) devices do not meet the definition of medical necessity.

The use of dynamic (LLPS) devices does not meet the definition of medical necessity for members unable to benefit from standard physical therapy modalities because of an inability to exercise or participate in the treatment plan after documentation of no improvement despite use for four (4) months.

The use of dynamic (LLPS) devices in the management of chronic contractures(no significant change in motion for a four (4) month period) OR chronic joint stiffness due to joint trauma, fractures, burns, head and spinal cord injuries, rheumatoid arthritis, multiple sclerosis, muscular dystrophy or cerebral palsy does not meet the definition of medical necessity.

Dynamic (LLPS) devices are considered experimental or investigational for use on any other joint or any other conditions/indications not listed above, including but not limited to the management of chronic joint stiffness and/or chronic or fixed contractures.

The use of patient-actuated serial stretch (PASS) and bi-directional static progressive (SP) devices is considered experimental or investigational for all indications. There is insufficient evidence in the published medical literature to permit conclusions on safety, efficacy and long-term outcomes.

BILLING/CODING INFORMATION:

The following code ranges represent both dynamic and static-progressive devices:

CPT Coding:

No specific CPT codes for these devices.

HCPCS Coding:

Note: There are no specific HCPCS codes for PASS devices.

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 (investigational)

E1802

Dynamic adjustable forearm pronation/supination device, includes soft interface material (investigational)

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 (investigational)

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 (investigational)

E1812

Dynamic knee, extension/flexion device with active resistance control

E1815

Dynamic adjustable ankle extension/flexion, includes soft interface material (investigational)

E1816

Static progressive stretch ankle device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories (investigational)

E1818

Static progressive stretch forearm pronation/supination device, with or without range of motion adjustment, includes all components and accessories (investigational)

E1820

Replacement soft interface material, dynamic adjustable extension/flexion device

E1821

Replacement soft interface material/cuffs for bi-directional static progressive stretch device (investigational)

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 and accessories (investigational)

E1840

Dynamic adjustable shoulder flexion/abduction/rotation device, includes soft interface material (investigational)

E1841

Static progressive stretch shoulder device, with or without range of motion adjustment, includes all components and accessories (investigational)

ICD-10 Diagnoses Codes That Support Medical Necessity: (Effective 10/01/15)

M12.521 – M12.529

Traumatic arthropathy, elbow

M12.531 – M12.539

Traumatic arthropathy, wrist

M12.541 – M12.549

Traumatic arthropathy, hand

M12.561 – M12.569

Traumatic arthropathy, knee

M17.10 – M17.5

Osteoarthritis of knee

M18.0 – M18.9

Osteoarthritis of first carpometacarpal joint

M19.021 – M19.029

Primary osteoarthritis, elbow

M19.031 – M19.039

Primary osteoarthritis, wrist

M19.041 – M19.049

Primary osteoarthritis, hand

M19.221 – M19.229

Secondary osteoarthritis, elbow

M19.231 – M19.239

Secondary osteoarthritis, wrist

M19.241 – M19.249

Secondary osteoarthritis, hand

M22.2x1 – M22.92

Disorder of patella

M23.00 – M23.92

Internal derangement of knee

M24.121 – M24.129

Other articular cartilage disorders, elbow

M24.131 – M24.139

Other articular cartilage disorders, wrist

M24.141 – M24.149

Other articular cartilage disorders, hand

M24.521 – M24.529

Contracture, elbow

M24.531 – M24.539

Contracture, wrist

M24.541 – M24.549

Contracture, hand

M24.561 – M24.569

Contracture, knee

M25.621 – M25.629

Stiffness of unspecified elbow, not elsewhere classified

M25.631 – M25.639

Stiffness of unspecified wrist, not elsewhere classified

M25.641 – M25.649

Stiffness of unspecified hand, not elsewhere classified

M25.661 – M25.669

Stiffness of unspecified knee, not elsewhere classified

S52.001A – S52.099S

Fracture of upper end of ulna

S52.101A – S52.189S

Fracture of upper end of radius

S52.201A – S52.299S

Fracture of shaft of ulna

S52.301A – S52.399S

Fracture of shaft of radius

S52.501A – S52.599S

Fracture of the lower end of radius

S52.601A – S52.699S

Fracture of lower end of ulna

S53.001A – S53.096S

Subluxation and dislocation of radial head

S53.101A – S53.196S

Subluxation and dislocation of ulnohumeral joint

S53.401A – S53.499S

Sprain of elbow

S56.001A – S56.499S

Injury of flexor muscle, fascia and tendon of finger

S62.001A – S62.92xS

Fracture at wrist and hand level

S63.001A – S63.92xS

Dislocation and sprain of joints and ligaments at wrist and hand level

S66.001 – S66.999S

Injury of muscle, fascia and tendon at wrist and hand level

S83.101A – S83.92xS

Dislocation and sprain of joints and ligaments of knee

S92.401A – S92.919S

Fracture of toe

S93.10A – S93.149S

Subluxation and dislocation of toe

REIMBURSEMENT INFORMATION:

If there is no significant improvement (i.e. documentation of progression toward goals, increased range of motion, advancing ability to perform activities of daily living (ADLs) or return to prior ability to perform ADLs) after four (4) months of use, dynamic (LLPS) devices do not meet the definition of medical necessity. The use of these devices beyond four (4) months is subject to medical review of documentation. Documentation should include changes in range of motion (ROM) to the affected joint, changes in the member’s ability to perform ADLs or perform activities outside the home.

LOINC Codes:

The following information may be required documentation to support medical necessity: Physician history and physical, attending physician treatment plan, progress notes, and visit notes.

Documentation Table

LOINC Codes

LOINC
Time Frame
Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Attending physician visit notes

18733-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Attending physician progress note

18741-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Treatment plan

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage Products: No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of the last guideline reviewed date

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

09-E0000-15 Continuous Passive Motion Device
01-97000-01 Physical Therapy (PT) and Occupational Therapy (OT)

OTHER:

None applicable.

REFERENCES:

  1. Berlet, G.C., Anderson, R.B., Davis, W.H., & Kiebzak, G.M. (2002). A prospective trial of night splinting in the treatment of recalcitrant plantar fasciitis: the ankle dorsiflexion Dynasplint. Orthopedics, 25(11), 1273-5.
  2. Blue Cross Blue Shield Association, Medical Policy Reference Manual: MPRM 1.03.05 Patient-actuated End Range Motion Stretching Devices, 01/15.
  3. Bonutti PM, McGrath MS, et al, Static Progressive Stretch for the Treatment of Knee Stiffness, Knee. 2008 Aug;15(4):272-6.
  4. Bonutti PM, McGrath MS, et al, Static Progressive Stretch Improves Range of Motion in Arthrofibrosis Following Total Knee Arthroplasty, Knee Surg Sports Traumatol Arthrosc. 2010 Feb;18(2):194-9.
  5. Bonutti, P.M., Windau, B.S., Ables, B.A., & Miller, B.G. (1994). Static progressive stretch to reestablish elbow range of motion. Clinical Orthopedics, 303, 128-134.
  6. Branch TP, Karsch RE, et al, Mechanical therapy for loss of knee flexion. Am J Orthop (Belle Mead NJ). 2003 Apr;32(4):195-200.
  7. ClinicalTrials.gov, Adhesive Capsulitis and Dynamic Splinting: a Randomized, Controlled Trial, sponsored by Dynasplint Systems, accessed 06/18/13.
  8. ClinicalTrials.gov, A Comparative Study of the Effectiveness of Treatment of Contractures with Mechanically Applied Stretch and Heat, sponsored by Robert Jones and Agnes Hunt Orthopaedic and District NHS Trust, accessed 06/18/13.
  9. ClinicalTrials.gov, Ankle Equinus Contracture Treated with Dynamic Splinting, sponsored by Dynasplint Systems, Inc, accessed 06/12.
  10. ClinicalTrials.gov, Dynamic Splinting after Total Knee Arthroplasty, sponsored by Dynasplint Systems, Inc, accessed 06/12.
  11. ClinicalTrials.gov, Dynamic Splinting for Excessive Pronation Following CVA (SupPro Botox), sponsored by Dynasplint Systems, Inc, accessed 06/18/13.
  12. ClinicalTrials.gov, Dynamic Splinting for Patients with Adhesive Capsulitis, sponsored by Dynasplint Systems, Inc, accessed 06/12.
  13. ClinicalTrials.gov, Dynasplint Therapy for Trismus in Head and Neck Cancer, sponsored by University of Alabama at Birmingham, accessed 06/12.
  14. ClinicalTrials.gov, Dynsaplint for Distal Radius Fracture, sponsored by Dynasplint Systems, Inc, accessed 02/11/11.
  15. ClinicalTrials.gov, The Effects of End-of-range Grade A+ Mobilization Following Acute Primary TKA, sponsored by University of Lausanne Hospitals, accessed 02/11/15.
  16. ClinicalTrials.gov, Progressive Splinting Status Post Elbow Fractures and Dislocations (JAS), sponsored by Vanderbilt University, accessed 06/12.
  17. ClinicalTrials.gov, A Prospective Randomized Trial of Rehabilitation With or Without Static Progressive Splinting for Wrist Stiffness, sponsored by Massachusetts General Hospital, accessed 02/11/15.
  18. Dempsey AL, Branch TP, et al, High-intensity mechanical therapy for loss of knee extension for worker’s compensation and non-compensation patients. Sports Med Arthrosc Rehabil Ther Technol. 2010 Oct 12;2:26.
  19. Dempsey AL, Mills T, Karsch RM, Branch TP, Maximizing total end range time is safe and effective for the conservative treatment of frozen shoulder patients. Am J Phys Med Rehabil. 2011 Sep;90(9):738-45.
  20. Department of Health and Human Services, Federal Register, 42 CFR Parts 414 and 484 Medicare Program; Home Health Prospective Payment system Rate Update for Calendar Year 2007 and Deficit Reduction Act of 2005 Changes to Medicare Payment for Oxygen Equipment and Capped Rental Durable Medical Equipment; Final Rule, 11/09/06.
  21. Doormberg JN, Ring D, et al, Static Progressive Splinting for Posttraumatic Elbow Stiffness, J Orthop Trauma. 2006 Jul;20(6):400-4.
  22. Gaspar PD, Willis FB, Adhesive capsulitis and dynamic splinting: a controlled, cohort study. BMC Musculoskeletal Disorders 2009, 10:111.
  23. Gelinas, J.J., Faber, K.J., Patterson, S.D., & King, G.J. (2000). The effectiveness of turnbuckle splinting for elbow contractures. Journal of Bone and Joint Surgery, 82(1), 74-78.
  24. Grissom SP, Blanton S, Treatment of Upper Motoneuron Plantarflexion Contractures by Using an Adjustable Ankle-Foot Orthosis, Arch Phys Med Rehabil. 2001 Feb;82(2):270-3.
  25. HAYES Medical Technology Directory “Mechanical Stretching Devices and Continuous Passive Motion for Joints of the Extremities” updated 08/07/08.
  26. Ibrahim MI, Johnson AJ, et al, Treatment of Adhesive Capsulitis of the Shoulder with a Static Progressive Stretch Device: A Prospective, Randomized Study, J Long Term Eff Med Implants. 2012;22(4):281-91.
  27. John MM, Willis FB, Dynamic Splinting for Hallux Valgus and Hallux Varus: A Pilot Study, The Foot and Ankle Online Journal 3 (1): 1, Jan 2010.
  28. Johnson AJ, McKenzie SA, et al, Assessment of Static Progressive Stretch for Treatment of Shoulder Stiffness. A Prospective Case Series. JLTMI; April2013;Vol22(4) 293-303.
  29. Joint Active Systems, Inc. website.
  30. King, G.J., & Faber, K.J. (2000). Post-traumatic elbow stiffness. Orthopedic Clinics of North America, 31(1).
  31. Light, K.E., Nuzik, S., Personius, W., & Barstrom, A. (1984). Low-load prolonged stretch vs. high-load brief stretch in treating knee contractures. Physical Therapy, 64(3), 330-333.
  32. Lindenhovius AL, Doornberg JN, et al, A Prospective Randomized Controlled Trial of Dynamic Versus Static Progressive Elbow Splinting for Posttraumatic Elbow Stiffness, J Bone Joint Surg AM. 2012; 94:694-100.
  33. Lucado AM, Li Z, et al, Changes in Impairment and Function After Static Progressive Splinting for Stiffness After Distal Radius Fracture, J Hand Ther. 2008 Oct-Dec;21(4):319-25.
  34. MacKay-Lyons, M. (1989). Low-load, prolonged stretch in treatment of elbow flexion contractures secondary to head trauma: a case report. Physical Therapy, 69(4), 292.
  35. Magnusson, S.P., Simonsen, E.B., Aagaard, P., & Kjaer, M. (1996). Biomechanical responses to repeated stretches in human hamstring muscle in vivo. American Journal of Sports Medicine, 24(5), 622.
  36. McClure, P.W., Blackburn, L.G., Dusold, C. (1994). The use of splints in the treatment of joint stiffness: biologic rationale and an algorithm for making clinical decisions. Physical Therapy, 74(12), 18.
  37. McGrath MS, Bonutti PM, et al, Static Progressive Splinting for Restoration of Rotational Motion of the Forearm, J Hand Ther. 2009 Jan-Mar;22(1):3-8.
  38. McElroy MJ, Costa CR, et al, Use of a Static Progressive Stretch Orthosis to Treat Post-Traumatic Ankle Stiffness, BMC Research Notes 2012, 5:348-356.
  39. Michlovitz SL, Harris BA, et al, Therapy Interventions for Improving Joint Range of Motion: A Systematic Review, J Hand Ther. 2004 Apr-Jun;17(2):118-31.
  40. Müller AM, Sadoghi P, et al, Effectiveness of Bracing in the Treatment of Nonosseous Restriction of Elbow Mobility: A Systematic Review and Meta-Analysis of 13 Studies; J Shoulder Elbow Surg. 2013 Aug;22(8):1146-52.
  41. National Guideline Clearinghouse (NGC); Agency for Healthcare Research and Quality (AHRQ). Guideline summary: Evidence-based care guideline for loss of elbow motion following surgery or trauma in children aged 4 to 18; accessed at guideline.gov 06/13.
  42. National Guideline Clearinghouse (NGC); Agency for Healthcare Research and Quality (AHRQ). Guideline summary: Guideline summary: Work Loss Data Institute. Ankle & Foot (Acute & Chronic); accessed at guideline.gov 06/13.
  43. National Guideline Clearinghouse (NGC); Agency for Healthcare Research and Quality (AHRQ). Guideline summary: Work Loss Data Institute. Elbow (Acute & Chronic); accessed at guideline.gov 02/15.
  44. National Guideline Clearinghouse (NGC); Agency for Healthcare Research and Quality (AHRQ). Guideline summary: Work Loss Data Institute. Forearm, Wrist, & Hand (Acute & Chronic), Not Including Carpal Tunnel Syndrome; accessed at guideline.gov 02/15.
  45. National Guideline Clearinghouse (NGC); Agency for Healthcare Research and Quality (AHRQ). Guideline summary: Work Loss Data Institute. Knee & Leg (Acute & Chronic); accessed at guideline.gov 02/15.
  46. National Guideline Clearinghouse (NGC); Agency for Healthcare Research and Quality (AHRQ). Guideline summary: Work Loss Data Institute. Shoulder (Acute & Chronic); accessed at guideline.gov 02/15.
  47. Neviaser AS, Hannafin JA, Adhesive Capsulitis: A Review of Current Treatment, Am J Sports Med. 2010 Nov;38(11):2346-56.
  48. Novotny, J.E. & Beynnon, B.D. (2003). Chapter 4 Biomechanics. In DeLee and Drez’s Orthopaedic Sports Medicine (2nd ed.). Philadelphia, PA: W.B. Saunders.
  49. Papotto BA, Mills T, Treatment of Severe Flexioni Deficits Following Total Knee Arthroplasty: A Randomized Clinical Trial, Orthop Nurs. 2012 Jan-Feb;31(1):29-34.
  50. Rhodes, V.J. (1991). Physical therapy management of patients with juvenile rheumatoid arthritis. Physical Therapy, 71(12), 910.
  51. Rompe JD, et al, Plantar Fascia-Specific Stretching Versus Radial Shock-Wave Therapy as Initial Treatment of Plantar Fasciopathy, The Journal of Bone and Joint Surgery (American), 2010; 92: 2514-2522.
  52. Schultz-Johnson K, Static Progressive Splinting, J HAND THER. 2002;15:163-178.
  53. Sharma NK, Loudon JK, Static Progressive Stretch Brace as a Treatment of Pain and Functional Limitations Associated with Plantar Fasciitis: A Pilot Study, Foot Ankle Spec 2012; 3; 117-124.
  54. Shelbourne, K.D., Patel, D.V., & Martini, D.J. (1996). Classification and management of arthrofibrosis of the knee after anterior cruciate ligament reconstruction. American Journal of Sports Medicine, 24(6).
  55. Sheridan L, Lopez A, et al, Plantar Fasciopathy Treated with Dynamic Splinting, Journal of the American Podiatric Medical Association, Vol 100 Number 3, 161-165, 2010.
  56. Shulman DH, Shipman B, Willis FB, Treating Trismus with Dynamic Splinting: A Case Report, Journal of Oral Science, Vol. 51, NO. 1, 141-144, 2009.
  57. Shulman DH, Shipman B, Willis FB, Treating Trismus with Dynamic Splinting: A Cohort, Case Series, Adv Ther. 2008: 25(1): 9-15.
  58. Steffen, T.M., Mollinger, L.A. & Harada, N. (1995). Low-load, prolonged stretch in the treatment of knee flexion contractures in nursing home residents. Physical Therapy, 75(10), 40.
  59. Stephenson JJ, Quimbo RA, Gu T, Knee-attributable medical costs and risk of re-surgery among patients utilizing non-surgical treatment options for knee arthrofibrosis in a managed care population, Curr Med Res Opin. 2010 May;26(5):1109-18.
  60. Thomas JL, et al, the Diagnosis and Treatment of Heel Pain: A Clinical Practice Guideline – Revision 2010, The Journal of Foot & Ankle Surgery 49 (2010) S1-S19; accessed at acfas.org 06/12.
  61. Uhl TL, Jacobs CA, Torque measures of common therapies for the treatment of flexion contractures. J Arthroplasty. 2011 Feb;26(2):328-34.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 03/26/15.

GUIDELINE UPDATE INFORMATION:

12/15/03

New Medical Coverage Guideline.

01/01/05

Code E1841 added with HCPCS update.

01/01/06

Annual HCPCS coding update: add E1812.

02/15/06

Biennial review; coverage unchanged.

07/15/07

Biennial review, coverage statements maintained, Medicare Advantage section updated, guideline reformatted, references updated.

01/01/08

2008 Annual HCPCS update: revised E1801, E1806, E1811, E1816, E1818, and E1841.

02/15/09

Biennial review: position statements maintained, MCG title, description section and references updated.

02/15/10

Annual Review: position statements maintained, description section, coding and references updated.

10/15/10

Revision; related ICD-10 codes added.

01/01/11

Annual HCPCS coding update. Added E1831.

04/15/11

Review; position statement maintained, description section, program exceptions, and references updated.

10/01/11

Revision; formatting changes

08/15/12

Review; position statements, description section, billing/coding, and references updated; formatting changes.

08/15/13

Annual Review; position statements, billing/coding information, and references updated; formatting changes.

11/15/13

Revision: references updated.

09/15/14

Annual review; position statement, reimbursement, and reference sections updated; formatting changes.

04/15/15

Review; position statement and references updated.

10/01/15

Revision; ICD10 coding section updated.

11/01/15

Revision: ICD-9 Codes deleted.

Date Printed: October 20, 2017: 12:01 PM