Note: Dynamic splinting systems include, but are not limited to, such products as Advance Dynamic ROM, Dynasplint, EMPI Advance Dynamic ROM, LMB Pro-glide, Pro-glide Dynamic ROM, SaeboFlex, SaeboReach, Stat-A-Dyne, and Ultraflex. 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.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 3 weeks after injury or surgery) or. Aetna considers dynamic splinting devices for the knee, elbow, wrist, finger, or toe medically necessary durable medical equipment (DME) if either of the following two selection criteria is met:
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