Does E1821 require prior authorization?

No, E1821 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

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`E1821`, Replacement soft interface material/cuffs for bi-directional static progressive

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium confidence)

Documentation Required

Documented signs and symptoms of significant motion stiffness/loss (clinical notes describing limitation in ROM and functional impact).
Documentation of timing relative to injury or surgery: either at least 3 weeks after injury or surgery (sub-acute/post-operative period) when used as adjunct to OT/PT, or documentation that the member is in the acute post-operative period following a second or subsequent surgery/procedure for that joint when there is a prior documented history of motion stiffness/loss.
Documentation of prior history of motion stiffness/loss for members receiving a device in the acute post-operative period after a second or subsequent surgery/procedure.

Key Coverage Criteria

Dynamic adjustable ankle extension/flexion device (e.g., JAS Ankle) for the treatment of contractures (refer to CPB 0565 - Ankle Orthoses, Ankle-Foot Orthoses (AFOs), and Knee-Ankle-Foot Orthoses (KAFOs)).
Dynamic splinting devices as durable medical equipment (DME) for the knee, elbow, wrist, finger, or toe when selection criteria are met.
Dynamic splinting devices used as an adjunct to occupational therapy or 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 3 weeks after injury or surgery).
Dynamic splinting devices for members who have a prior documented history of motion stiffness/loss in a joint, have had a surgery or procedure done to improve motion to that joint, and are in the acute post-operative period following a second or subsequent surgery or procedure.
Coverage tied to applicable CPT/HCPCS codes when the above selection criteria are met (examples of covered CPT codes: 29126, 29131, 29505, 29515; examples of covered HCPCS codes: E1800, E1802, E1805, E1810, E1815, E1825, E1830, E1831).
Covered ICD-10 diagnosis codes when selection criteria are met include contracture, ankle and foot (M24.571 - M24.576).

2 Active Policies

ANTHEM-DME.00038, Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices

AETNA-CPB-0405, Mechanical Stretching Devices for Contracture and Joint Stiffness

`E1821`, Replacement soft interface material/cuffs for bi-directional static progressive

Prior Authorization

Documentation Required

Key Coverage Criteria

2 Active Policies

Related Codes

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E1821, Replacement soft interface material/cuffs for bi-directional static progressive

Prior Authorization

Documentation Required

Key Coverage Criteria

2 Active Policies

Related Codes

Have a follow-up question?

`E1821`, Replacement soft interface material/cuffs for bi-directional static progressive