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 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)
Table 0678 — Dynamic Adjustable Extension/Flexion Devices.
Source:
Rule 410-122-0678 — Dynamic Adjustable Extension/Flexion Device, https://secure.sos.state.or.us/oard/view.action?ruleNumber=410-122-0678.