E1801 Sps/pass elbow deviceStatic progressive stretch/patient actualized serial stretch elbow device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories
4 of 4 payer prior-auth lists that name E1801 require prior authorization or set conditions: Humana, Rocky Mountain Health Plans, UnitedHealthcare Community Plan.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Humana | Humana Healthy Horizons | KY | prior auth required | Jan 1, 2027 | please visit Humana Healthy Horizons in Kentucky Clinical coverage policies. | |
| Rocky Mountain Health Plans | Rocky Mountain Medicare Advantage D-SNP | CO | prior auth required | Feb 1, 2025 | Rocky Mountain Health Plans Medicare Advantage Dual-Special Needs Plans – prior authorization Effective February 1, 2025 | |
| UnitedHealthcare Community Plan | UnitedHealthcare Community Plan of Kentucky | KY | prior auth under conditions | Cost over $500 | Jul 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Kentucky Effective July 1, 2026 |
| UnitedHealthcare Community Plan | UnitedHealthcare Connected (Texas MMP) | TX | prior auth under conditions | Prior authorization is required only for a retail purchase or cumulative rental cost of more than $1,000. | Jan 1, 2015 | Prior authorization requirements for UnitedHealthcare Connected (Medicare-Medicaid Plan) Texas Effective November 1, 2025 This list contains prior authorization review requirements for participating U |
E1801 appears in 21 coverage policies from Aetna, Anthem, Blue Cross & Blue Shield of Mississippi, Blue Cross & Blue Shield of Rhode Island, Blue Cross Blue Shield of Massachusetts, Blue Shield of California, BlueCross BlueShield of South Carolina, Centene, UnitedHealthcare.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Mechanical Stretching Devices for Contracture and Joint Stiffness (0405) | not covered | Jun 30, 2026 | payer document |
| Aetna | Orthopedic Casts, Braces and Splints (0009) | listed, no stance (range E1800-E1840) | Jan 20, 2026 | payer document |
| Anthem | Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices (DME.00038) | unproven / investigational | May 14, 2026 | payer document |
| Blue Cross & Blue Shield of Mississippi | Patientcontrolled End Range Of Motion Stretching Devices | unproven / investigational | payer document | |
| Blue Cross & Blue Shield of Rhode Island | Patient-Controlled End of Range Motion Stretching Devices sad | not covered | Apr 1, 2026 | payer document |
| Blue Cross Blue Shield of Massachusetts | Patient-Controlled End of Range Motion Stretching Devices (721) | unproven / investigational | payer document | |
| Blue Shield of California | Patient-Controlled End Range of Motion Stretching Devices (1.03.05) | listed, no stance | payer document | |
| BlueCross BlueShield of South Carolina | Knee Braces, Orthopaedic Casts, Splints (CAM 147) | listed, no stance | Jan 1, 2026 | payer document |
| BlueCross BlueShield of South Carolina | Patient-Controlled End of Range Motion Stretching Devices (CAM 10305) | listed, no stance | Feb 1, 2026 | payer document |
| Centene | Mechanical Stretching Devices for Joint Stiffness and Contracture (CP.MP.144) | not covered | Oct 1, 2025 | payer document |
| UnitedHealthcare | Durable Medical Equipment (DME), Prosthetics, Orthotics (Non-Foot Orthotics), Nutritional Therapy, and Medical Supplies Grid (MMP028.23) Progressive Stretch | LCDs/LCAs do not exist at this time. | listed, no stance | Oct 1, 2025 | payer document |
| UnitedHealthcare | Mechanical Stretching Devices (2026T0481BB) | listed, no stance | Jan 1, 2026 | payer document |
| UnitedHealthcare | Mechanical Stretching Devices (CS077.R) | listed, no stance | Dec 1, 2025 | payer document |
| UnitedHealthcare | Mechanical Stretching Devices (for Idaho Only) (CS077ID.D) | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Mechanical Stretching Devices (for Kansas Only) (CS077KS.03) | listed, no stance | Dec 1, 2025 | payer document |
| UnitedHealthcare | Mechanical Stretching Devices (for Kentucky Only) (CS077KY.09) | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Mechanical Stretching Devices (for Nebraska Only) (CS077NE.R) | listed, no stance | Dec 1, 2025 | payer document |
| UnitedHealthcare | Mechanical Stretching Devices (for New Mexico Only) (CS077NM.E) | listed, no stance | Dec 1, 2025 | payer document |
| UnitedHealthcare | Mechanical Stretching Devices (for Ohio Only) (CS077OH.F) | listed, no stance | Jan 1, 2026 | payer document |
| UnitedHealthcare | Mechanical Stretching Devices (for Pennsylvania Only) (CS077PA.P) | listed, no stance | Dec 1, 2025 | payer document |
| UnitedHealthcare | Mechanical Stretching Devices (for Tennessee Only) (CS077TN.P) | listed, no stance | Dec 1, 2025 | payer document |
Prior authorization required or conditional in CO, IL, IN, KY, MA, MD, MS, NE, OH, VA.
From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.