OAR 410-122-0678: Dynamic Adjustable Extension/Flexion Device

(1) Indications and limitations of coverage and medical appropriateness: The Division may cover some dynamic adjustable extension/flexion devices for a covered condition when all of the following conditions are met: (a) As an adjunct to physical therapy for clients with signs and symptoms of persistent joint stiffness in the sub-acute injury or post-operative period (> 3 weeks but < 4 months after injury or surgical procedure) when the device is applied and managed under the direct supervision of a physical therapist; (b) As an adjunct to physical therapy in the acute post-operative period for clients who are undergoing additional surgery to improve the range of motion of a previously affected joint when the device is managed under the direct supervision of a physical therapist; (c) For this episode, the device has not been billed to the Division with a current procedure terminology (CPT) code, healthcare common procedure coding system (HCPCS) code, or diagnosis code by any other healthcare provider; (d) Reimbursement is limited to a maximum of four (4) months per episode; (e) Reimbursement is on a month-to-month rental basis only. (2) Documentation requirements: (a) Submit medical records that support the conditions of coverage, as specified in this rule, have been met, including the treatment plan from the physical therapist; (b) The treatment plan shall include: (A) Baseline measurements (pre-intervention measurements) of range of motion (ROM) limitations; (B) Weekly ROM measurements with documented 10 degree improvement. (3) Refer to Table 122-0678 — Dynamic Adjustable Extension/Flexion Devices for HCPCS codes. [ED. NOTE: To view attachments referenced in rule text, click here to view rule.]