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.
[ED. NOTE: Tables referenced are available from the agency.]
[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

Source: Rule 410-122-0678 — Dynamic Adjustable Extension/Flexion Device, .

410‑122‑0010
Definitions 410‑122‑0020
Orders 410‑122‑0040
Prior Authorization 410‑122‑0080
Conditions of Coverage, Limitations, and Restrictions 410‑122‑0090
Face-to-Face Encounter Requirements (for Fee-For-Service Clients) 410‑122‑0180
Healthcare Common Procedure Coding System Level II Coding 410‑122‑0182
Legend 410‑122‑0184
Repairs, Servicing, Replacement, Delivery, and Dispensing 410‑122‑0186
Payment Methodology 410‑122‑0188
DMEPOS Rebate Agreements 410‑122‑0200
Pulse Oximeter for Home Use 410‑122‑0202
Positive Airway Pressure (PAP) Devices for Adult Obstructive Sleep Apnea 410‑122‑0203
Oxygen and Oxygen Equipment 410‑122‑0204
Nebulizer 410‑122‑0205
Respiratory Assist Devices 410‑122‑0206
Intermittent Positive Pressure Breathing 410‑122‑0207
Respiratory Supplies 410‑122‑0208
Suction Pumps 410‑122‑0209
Tracheostomy Care Supplies 410‑122‑0210
Ventilators 410‑122‑0211
Cough Stimulating Device 410‑122‑0220
Pacemaker Monitor 410‑122‑0240
Apnea Monitors for Infants 410‑122‑0250
Breast Pumps 410‑122‑0260
Home Uterine Monitoring 410‑122‑0280
Heating/Cooling Accessories 410‑122‑0300
Light Therapy 410‑122‑0320
Manual Wheelchair Base 410‑122‑0325
Power Wheelchair Base 410‑122‑0330
Power-Operated Vehicle 410‑122‑0340
Wheelchair Options/Accessories 410‑122‑0360
Canes and Crutches 410‑122‑0365
Standing and Positioning Aids 410‑122‑0375
Walkers 410‑122‑0380
Hospital Beds 410‑122‑0400
Pressure Reducing Support Surfaces 410‑122‑0420
Hospital Bed Accessories 410‑122‑0475
Therapeutic Shoes for Diabetics 410‑122‑0510
Osteogenesis Stimulator 410‑122‑0515
Neuromuscular Electrical Stimulator (NMES) 410‑122‑0520
Glucose Monitors and Diabetic Supplies 410‑122‑0525
External Insulin Infusion Pump 410‑122‑0540
Ostomy Supplies 410‑122‑0560
Urological Supplies 410‑122‑0580
Bath Supplies 410‑122‑0590
Patient Lifts 410‑122‑0600
Toilet Supplies 410‑122‑0620
Miscellaneous Supplies 410‑122‑0625
Surgical Dressing 410‑122‑0630
Incontinent Supplies 410‑122‑0640
Eye Prostheses 410‑122‑0655
External Breast Prostheses 410‑122‑0658
Gradient Compression Stockings/Sleeves 410‑122‑0660
Orthotics and Prosthetics 410‑122‑0662
Ankle-Foot Orthoses and Knee-Ankle-Foot Orthoses 410‑122‑0678
Dynamic Adjustable Extension/Flexion Device 410‑122‑0680
Facial Prostheses 410‑122‑0700
Negative Pressure Wound Therapy Pumps 410‑122‑0720
Pediatric Wheelchairs
Last Updated

Jun. 8, 2021

Rule 410-122-0678’s source at