MEDICAL POLICY

POLICY RELATED POLICIES POLICY GUIDELINES DESCRIPTION SCOPE BENEFIT APPLICATION RATIONALE REFERENCES CODING APPENDIX HISTORY

Stretching Devices for Joint Stiffness and Contracture Number 1.01.514 Effective Date January 12, 2016 Revision Date(s) 09/13/16; 01/12/16; 02/10/15; 02/10/14; 02/11/13; 03/13/12; 02/08/11; 01/12/10; 01/13/09; 01/08/08; 01/09/07; 01/10/06, 01/11/05 Replaces N/A

Policy [TOP]

Mechanical (dynamic) stretching devices for joint stiffness or contracture may be considered medically necessary durable medical equipment (DME) when the criteria are met for ONE of the following:  As an adjunct to physical therapy for 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 but less than 4 months after injury or surgery); or  In the acute post-operative period for members who have a documented prior history of motion stiffness/loss in a joint and are having additional surgery or procedures done to improve motion of the affected joint Mechanical (dynamic) stretching devices may be considered medically necessary only when part of a structured physical therapy program following a recent injury or surgery. Mechanical (dynamic) stretching devices is considered not medically necessary if there is no measurable improvement after four months of use. Mechanical (dynamic) stretching devices is considered not medically necessary in the prophylactic management of chronic contractures (that is-no significant change in motion occurred for a 4-month period) and chronic joint stiffness due to joint trauma, fractures, burns, head and spinal cord injuries, rheumatoid arthritis, multiple sclerosis, muscular dystrophy or cerebral palsy, and other chronic neuromuscular conditions.

Related Policies [TOP]

1.03.05

Patient-Actuated End Range Motion Stretching Devices

Policy Guidelines [TOP]

Coding HCPCS

E1800 E1802 E1805 E1810 E1812 E1815 E1820 E1821 E1825 E1830 E1840

Dynamic adjustable elbow extension/flexion device, includes soft interface material Dynamic adjustable forearm pronation/supination device, includes soft interface material Dynamic adjustable wrist extension/flexion device, includes soft interface material Dynamic adjustable knee extension/flexion device, includes soft interface material Dynamic knee, extension/flexion device with active resistance control Dynamic adjustable ankle extension/flexion device, includes soft interface material Replacement soft interface material, dynamic adjustable extension/flexion device Replacement soft interface material/cuffs for bi-directional static progressive stretch device Dynamic adjustable finger extension/flexion device, includes soft interface material Dynamic adjustable toe extension/flexion device, includes soft interface material Dynamic adjustable shoulder flexion/abduction/rotation device, includes soft interface material

Description [TOP]

Joint stiffness or contractures are commonly caused by immobilization following injury, surgery or a disease process. A joint contracture can occur at any joint in the body and is characterized by a decreased range of motion due to structural changes in muscles, tendons, ligaments and skin that occur when elastic connective tissue is replaced with inelastic fibrous material that is resistant to stretching.

Low-load Prolonged-duration Stretch (LLPS) Devices/Dynamic Splinting Systems Dynamic splinting systems are spring-loaded, adjustable devices designed to provide low-load prolonged-duration stretch (LLPS) while patients are asleep or at rest. Dynamic splinting units (for both extension as well as flexion) are available for elbow, wrist, fingers, knee, ankle and toes. These units are being marketed for the treatment of joint stiffness due to immobilization or limited range of motion (ROM) as a consequence of fractures, dislocations, tendon and ligament repairs, joint arthroplasties, total knee replacements, burns, rheumatoid arthritis, hemophilia, tendon releases, head trauma, spinal cord injuries, cerebral palsy, multiple sclerosis, and other traumatic and non-traumatic disorders. Dynamic splinting is commonly used in the post-operative period for the prevention or treatment of motion stiffness/loss in the knee, elbow, wrist or finger. It is not generally used in other joints such as the hip, ankle or foot. Product names commonly encountered on the market for dynamic splinting systems include: Dynasplint™, EMPI Advance™, LMB Pro-glide™, SaeboFlex™, and Ultraflex™.

Flexionators and Extensionators The shoulder flexionator (ERMI Shoulder Flexionater®) is designed to isolate and treat decreased glenohumeral abduction and external rotation. The device is intended to address the needs of patients with excessive scar tissue. This customizable device has biomechanically and anatomically located pads to focus treatment on the glenohumeral joint, without stressing the other shoulder joints. Once customized, the shoulder flexionator can be used by the patient at home without assistance to perform serial stretching exercises, alternately stretching and relaxing the scar tissue surrounding the glenohumeral joint. The device has three sections: the main frame, arm unit, and pump unit. The shoulder flexionator was listed with the FDA in 2001, and is Class I exempt. The knee/ankle flexionator (ERMI Knee/Ankle Flexionater®) is a self-contained device that facilitates recovery from decreased range of motion of the knee and/or ankle joints. The knee flexionator is designed to address the needs of patients with arthrofibrosis (excessive scar tissue within and around a joint). The knee/ankle flexionator is a variable load/variable position device that uses a hydraulic pump and quick-release mechanism to allow patients to perform dynamic stretching exercises in the home without assistance, alternately stretching and relaxing the scar tissue surrounding affected joints. The knee/ankle flexionator includes a frame to house hydraulic components, a pump handle and quick release valve for patient control, supporting footplate and

specially incorporated padded chair. The frame attaches to a folding chair and is adjustable to accommodate treatment of either extremity, or both extremities simultaneously. The load potential ranges from a few ounces up to 500 foot-pounds. The knee/ankle flexionator was listed with the FDA in 2002, and is Class I exempt. The knee extensionator (ERMI Knee Extensionater®) and elbow extensionator (ERMI Shoulder Extensionater®) provide serial stretching, using a patient-controlled pneumatic device that can deliver variable loads to the affected joint. The manufacturer claims that the knee and shoulder extensionators are the only devices on the market that can “consistently stretch scar tissue, without causing vascular re-injury and thereby significantly reduce the need for additional surgery” (ERMI, 2002). The extensionator telescopes to the appropriate length, and is applied to the leg with Velcro straps. During a typical training session, the joint is stretched from 1 to 5 minutes, and then is allowed to recover for an equal length of time, and is then stretched again. A typical training session lasts 15 minutes, and the usual prescription is to perform 4 to 8 training sessions per day.

Joint Active Systems (JAS) Splints JAS splints (e.g., JAS Elbow, JAS Shoulder, JAS Ankle, JAS Knee, JAS Wrist, and JAS Pronation-Supination) (Joint Active Systems, Effingham, IL) use bi-directional static progressive stretch. Typically, the patient sets the device angle at the beginning of the session, and every several minutes the angle is increased. A typical session lasts 30 minutes, and sessions may be repeated up to three times per day. Unlike the flexionator, the joint is not allowed to recover during the stretch period. According to the manufacturer, JAS systems are designed to simulate manual therapy. The manufacturer claims that JAS devices eliminate the risk of joint compression, provide soft tissue distraction, and “achieve permanent soft tissue lengthening in a short amount of time.” There are no prospective randomized studies demonstrating that the addition of the use of JAS devices to the physical therapy management of patients with joint injury or surgery significantly improves patient's clinical outcomes.

Scope [TOP]

Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply. This medical policy does not apply to Medicare Advantage.

Benefit Application [TOP]

N/A

Rationale [TOP]

This policy was originally created in 2005 and has been updated based on searches of the MEDLINE database. The most recent literature search was performed for the period of April 2012 through January 2014. The following is a summary of the key findings since the policy was created to date. Tan and colleagues (2007) report on postoperative dynamic extension splinting compared with fixation with Kirschner wires and static splinting in contractures of burned hands. The main disadvantage of skin grafting is a tendency to contract again. The authors compared the outcomes of dynamic and static splinting postoperatively. Fifty-seven patients were studied over a period of 9 years. Thirty six patients (44 hands) had Kirschner (K) wires applied with static splints; twenty-one patients (26 hands) had dynamic splinting. The mean age was 11 (range 237) and 15 (range 2-50) years in the two groups. Before and after the operation, basic hand functions were evaluated clinically, and the results analyzed statistically. The mean follow-up times were 18 and 14 months

respectively, and recurrence rates were 22% and 14%. The authors concluded that postoperative dynamic splinting is superior to fixation with K-wires with or without static splints.(1) Berner and Willis (2010) performed a retrospective review of 133 patients with wrist flexion contracture who were treated with a Wrist Extension Dynasplint (WED) following distal radius fractures. Their purpose was to evaluate the initial effect of dynamic splinting as a home therapy on wrist extension (active range of motion {AROM}), in both surgical and non-surgical patients. Their results showed a significant improvement in AROM for all patients after a mean duration of 3.9 weeks of dynamic splinting. Patients showed a mean 62% increase in active extension. There was not a significant difference between patients receiving surgery and those not receiving surgery. The authors concluded that dynamic splinting contributed 138 to 185 hours of stretching in their first month following fracture and was directly responsible for an increase of 16 degrees AROM measurement.(2) Sameem et al. (2011) reported on a systematic review stating that controversy exists as to which rehabilitation protocol provides the best outcomes for patients after surgical repair of the extensor tendons of the hand. These researchers determined which rehabilitation protocol yields the best outcomes with respect to ROM and grip strength in extensor zones V-VIII of the hand. A comprehensive literature review and assessment was undertaken by 2 independent reviewers. Methodological quality of randomized controlled trials (RCTs) and cohort studies was assessed using the Scottish Intercollegiate Guidelines Network scale. A total of 17 articles were included in the final analysis (κ = 0.9). From this total, 7 evaluated static splinting, 12 evaluated dynamic splinting, and 4 evaluated early active splinting. Static splinting yielded "excellent/good" results ranging from 63 % (minimum) to 100 % (maximum) on the total active motion (TAM) classification scheme and TAM ranging from 185 (minimum) to 258 (maximum) across zones V-VIII. Dynamic splinting studies demonstrated a percentage of "excellent/good" results ranging from 81 % (minimum) and 100 % (maximum) and TAM ranging from 214 (minimum) and 261 (maximum). Early active splinting studies showed "excellent/good" results ranging from 81 % (minimum) and 100 % (maximum). Only 1 study evaluated TAM in zones V-VIII, which ranged from 160 (minimum) and 165 (maximum) when using 2 different early active modalities. The authors’ conclusion is that the available level 3 evidence suggested better outcomes when using dynamic splinting over static splinting. The authors that before a conclusive recommendation can be made, additional studies comparing dynamic and early active motion protocols are needed.(3) John et al. (2011) stated that hallux limitus (HL) is a pathology of degenerative arthritis in the first metatarsophalangeal joint (MTJ) of the great toe with the onset commonly occurring after, a bunionectomy or a cheilectomy surgery. A total of 50 patients (aged 29 to 69 years) diagnosed with post-operative HL were enrolled in a randomized controlled trial (RCT). The duration of this study was 8 weeks, and all patients received nonsteroidal anti-inflammatory drugs, orthotics, and instructions for a home exercise program. Experimental patients were also treated with dynamic splinting for first MTJ extension (60 minutes, 3 times per day). The dependent variable was change in active ROM (AROM). A repeated measures analysis of variance was used with independent variables of patient categories, surgical procedure (cheilectomy versus bunionectomy) and duration since surgery. There was a significant difference in change of AROM for experimental versus control patients (p < 0.001, T = 4.224, n = 48); there was also a significant difference for patient treated within 2 months of surgery (p = 0.0221). The authors concluded that dynamic splinting was effective in reducing contracture of post-operative hallux limitus in this study; experimental patients gained a mean 250 % improvement in AROM. The authors state that this modality should be considered for standard of care in treating post-operative hallux limitus. (4) In 2013, Furia and colleagues performed a systematic review to evaluate the safety and efficacy of dynamic splinting as it is used to treat joint contracture in lower extremities, and to determine if duration on total hours of stretching had an effect on outcomes. They found that the mean aggregate change in AROM was 23.5º in the eight studies examined. Dynamic splinting with prolonged, passive stretching as home therapy treatment showed a significant direct, linear correlation between the total number of hours in stretching and restored AROM. No adverse events were reported. Furia concluded that dynamic splinting was a safe and efficacious treatment for lower extremity joint contractures. Further, he stated that joint specific stretching protocols accomplished greater durations of end-range stretching which may be considered to be responsible for connective tissue elongation. There are no published professional society positions found that address the use of stretching devices.

Summary In the sub-acute injury or post-operative period, select patients may benefit from treatment with active and passive ranges of motion exercises, as well as progressive splinting/dynamic stretching devices as interventions

for joint stiffness or contracture. Several FDA approved commercial devices are available that are designed as an integral component of physical therapy to improve mobilization of stiff joints or in the rehabilitation of soft tissue around joints. There is no evidence that one type of joint contracture device is superior over others. Although there is insufficient data in the peer reviewed literature to validate the effectiveness of these devices, this technology is widely used in the Orthopedic, Rehabilitation Medicine and Physical Therapy communities and has become a community standard.

References [TOP]

1. Tan O, Atki B, Dogan A et al. Postoperative dynamic extension splinting compared with fixation with Kirschner wires and static splinting in contractures of burned hands: a comparative study of 57 cases in 9 years. Scan J Plast Reconstr Surg Hand Surg. 2007;41(4):197-202 2. Berner SH, Willis FB. Dynamic splinting in wrist extension following distal radius fractures. Journal of Orthopaedic Surgery and Research 2010. 5:53. 3. Sameem M, Wood T, Ignacy T, et al. A systematic review of rehabilitation protocols after surgical repair of the extensor tendons in zones V-VIII of the hand. J Hand Ther. 2011; 24(4):365-372. 4. John MM, Kalish S, Perns SV, Willis FB. Dynamic splinting for postoperative hallux limitus: A randomized, controlled trial. J Am Podiatr Med Assoc. 2011; 101(4):285-288. Additional resources and websites: 1. Richard R, Shanesy CP, Miller SF. Dynamic versus Static Splints: A Prospective Case for Sustained Stress. J Burn Care Rehabilitation, 1995; 16(3 pt 1):284-7. 2. Cohen EJ. Adjunctive Therapy Devices: Restoring ROM Outside of the Clinic. Phys Ther Magazine, 1995; 10-13. 3. Jansen, CM, Windau JE, Bonutti PM et al. Treatment of a Knee Contracture Using a Knee Orthosis Incorporating Stress-Relaxation Techniques. Phys Ther, 1996; 76(2):182-186. 4. Joint Active Systems, Inc. JAS OnLine (website). Effingham, IL: Joint Active Systems, 2002; available at http://www.jointactivesystems.com. Last accessed December 2015. 5. Chester DL, Beale S, Beveridge L et al. A Prospective, Controlled, Randomized Trail Comparing Early Active Extension with Passive Extension Using a Dynamic Splint in the Rehabilitation of Repaired Extensor Tendons. J Hand Surg, 2002; 27(3):283-8. 6. Harvy L, Herbert R, Crosbie J. Does Stretching Induce Lasting Increases in Joint ROM? A Systematic Review. Physiother Res Int, 2002; 7(1):1-13. 7. Branch TP, Karsch RE, Mills TJ, Palmer MT. Mechanical Therapy for Loss of Knee Flexion. Am J Orthop, 2003; 32(4):195-200. 8. Egan M, Brosseau L, Farmer M et al. Splints and Orthosis for Treating Rheumatoid Arthritis (Cochrane Review) in The Cochrane Library, Issue 3, 2003; Oxford, UK: Update Software. 9. Washington State Department of Labor and Industries, Office of the Medical Director. ERMI Flexionators and Extensionators. Health Technology Assessment Brief. Olympia, WA: Washington State Department of Labor and Industries; updated June 6, 2003. Available at: http://www.lni.wa.gov/ClaimsIns/Files/OMD/ermi.pdf Last accessed December 2015. 10. Michlovitz, SL, Harris BA, Watkins MP. Therapy Interventions for Improving Joint Range of Motion: A Systematic Review. J Hand Ther. 2004; 17(2):118-31.Hayes Inc. Hayes Medical Technology Directory. Mechanical Stretching Devices for the Treatment of Joint Contractures of the Extremities. Lansdale, PA: Hayes, Inc.; November 2014. 11. Furia JP, Willis FB, Shanmugam R, Curran SA. Systematic review of contracture reduction in the lower extremity with dynamic splinting. Adv Ther. 2013;30(8):763-70.

Coding [TOP]

Codes

Number

Description

HCPCS

E1800 E1802 E1805 E1806

E1810 E1812 E1815 E1820 E1821 E1825 E1830 E1840

Dynamic adjustable elbow extension/flexion device, includes soft interface material Dynamic adjustable forearm pronation/supination device, includes soft interface material Dynamic adjustable wrist extension/flexion device, includes soft interface material Static progressive stretch wrist device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories Dynamic adjustable knee extension/flexion device, includes soft interface material Dynamic knee, extension/flexion device with active resistance control Dynamic adjustable ankle extension/flexion device, includes soft interface material Replacement soft interface material, dynamic adjustable extension/flexion device Replacement soft interface material/cuffs for bi-directional static progressive stretch device Dynamic adjustable finger extension/flexion device, includes soft interface material Dynamic adjustable toe extension/flexion device, includes soft interface material Dynamic adjustable shoulder flexion/abduction/rotation device, includes soft interface material

Appendix [TOP]

N/A

History [TOP]

Date 1/11/05 1/10/06 04/21/06 05/26/06 01/09/07 01/08/08 01/13/09 01/12/10 02/08/11 03/23/12 02/11/13

02/24/14

Reason Add to Durable Medical Equipment - New policy Replace Policy - Policy updated with literature search; policy statement unchanged. Title changed for clarification (old title: Mechanical Stretching Devices for Joint Stiffness and Contracture). Codes Updated - No other changes Update Scope and Disclaimer - No other changes. Replace Policy - Policy updated with literature review; references added; no change in policy statement. Replace Policy - Policy updated with literature review; no change in policy statement. Replace Policy - Policy updated with literature review, no change in policy statement. Reference added. Replace Policy - Policy updated with literature review, no change in policy statement. Replace Policy - Policy updated with literature review, no change in policy statement. Reference added. New code E1831 added. Replace Policy. Policy reviewed. No change in policy statement. Replace policy. Policy section updated with 2 statements: Mechanical (dynamic) stretching devices may be considered not medically necessary when not part of a structured physical therapy program following a recent injury or surgery. Mechanical (dynamic) stretching devices may be considered not medically necessary if there is no significant improvement after four months of use. Rationale section revised based on a literature search through January 2013. Rationale reformatted to delete years without any literature update or addition of references. References 3-4 added; others renumbered or removed. Policy statement changed as noted. Replace policy. No change to policy statement. Added Hayes reference.

02/25/15 03/19/15 01/12/16 09/13/16

Annual Review. No change to policy statement. Policy updated with literature review. Added reference and Hayes reference updated. Update Related Policies. Add 1.03.05. Annual Review. No change to policy statement. Coding update.Remove codes E1801, E1811, E1816, E1818, E1831, and E1841; they are not specific to dynamic stretching devices which is the scope of this policy.

Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). ©2016 Premera All Rights Reserved.

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037338 (07-2016)

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日本語 (Japanese): この通知には重要な情報が含まれています。この通知には、Premera Blue Cross の申請または補償範囲に関する重要な情報が含まれている場合があ ります。この通知に記載されている可能性がある重要な日付をご確認くだ さい。健康保険や有料サポートを維持するには、特定の期日までに行動を 取らなければならない場合があります。ご希望の言語による情報とサポー トが無料で提供されます。800-722-1471 (TTY: 800-842-5357)までお電話 ください。

Română (Romanian): Prezenta notificare conține informații importante. Această notificare poate conține informații importante privind cererea sau acoperirea asigurării dumneavoastre de sănătate prin Premera Blue Cross. Pot exista date cheie în această notificare. Este posibil să fie nevoie să acționați până la anumite termene limită pentru a vă menține acoperirea asigurării de sănătate sau asistența privitoare la costuri. Aveți dreptul de a obține gratuit aceste informații și ajutor în limba dumneavoastră. Sunați la 800-722-1471 (TTY: 800-842-5357).

한국어 (Korean): 본 통지서에는 중요한 정보가 들어 있습니다. 즉 이 통지서는 귀하의 신청에 관하여 그리고 Premera Blue Cross 를 통한 커버리지에 관한 정보를 포함하고 있을 수 있습니다. 본 통지서에는 핵심이 되는 날짜들이 있을 수 있습니다. 귀하는 귀하의 건강 커버리지를 계속 유지하거나 비용을 절감하기 위해서 일정한 마감일까지 조치를 취해야 할 필요가 있을 수 있습니다. 귀하는 이러한 정보와 도움을 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 800-722-1471 (TTY: 800-842-5357) 로 전화하십시오.

Pусский (Russian): Настоящее уведомление содержит важную информацию. Это уведомление может содержать важную информацию о вашем заявлении или страховом покрытии через Premera Blue Cross. В настоящем уведомлении могут быть указаны ключевые даты. Вам, возможно, потребуется принять меры к определенным предельным срокам для сохранения страхового покрытия или помощи с расходами. Вы имеете право на бесплатное получение этой информации и помощь на вашем языке. Звоните по телефону 800-722-1471 (TTY: 800-842-5357).

ລາວ (Lao): ແຈ້ ງການນ້ີ ມີຂ້ໍ ມູ ນສໍາຄັ ນ. ແຈ້ ງການນ້ີ ອາດຈະມີຂ້ໍ ມູ ນສໍາຄັ ນກ່ ຽວກັ ບຄໍາຮ້ ອງສະ ໝັ ກ ຫື ຼ ຄວາມຄຸ້ ມຄອງປະກັ ນໄພຂອງທ່ ານຜ່ ານ Premera Blue Cross. ອາດຈະມີ ວັ ນທີສໍາຄັ ນໃນແຈ້ ງການນີ້. ທ່ ານອາດຈະຈໍາເປັນຕ້ ອງດໍາເນີນການຕາມກໍານົ ດ ເວລາສະເພາະເພື່ອຮັ ກສາຄວາມຄຸ້ ມຄອງປະກັ ນສຸ ຂະພາບ ຫື ຼ ຄວາມຊ່ ວຍເຫື ຼ ອເລື່ອງ ຄ່ າໃຊ້ ຈ່ າຍຂອງທ່ ານໄວ້ . ທ່ ານມີສິດໄດ້ ຮັ ບຂ້ໍ ມູ ນນ້ີ ແລະ ຄວາມຊ່ ວຍເຫື ຼ ອເປັນພາສາ ຂອງທ່ ານໂດຍບໍ່ເສຍຄ່ າ. ໃຫ້ ໂທຫາ 800-722-1471 (TTY: 800-842-5357). ភាសាែខម រ (Khmer): េសចកត ីជូនដំណឹងេនះមានព័ត៌មានយា៉ងសំខាន់។ េសចកត ីជូនដំណឹងេនះរបែហល ជាមានព័ត៌មានយា៉ងសំខាន់អំពីទរមង់ែបបបទ ឬការរា៉ប់រងរបស់អនកតាមរយៈ Premera Blue Cross ។ របែហលជាមាន កាលបរ ិេចឆ ទសំខាន់េនៅកនុងេសចកត ីជូន ដំណឹងេនះ។ អន ករបែហលជារតូវការបេញច ញសមតថ ភាព ដល់កំណត់ៃថង ជាក់ចបាស់ នានា េដើមបីនឹងរកសាទុកការធានារា៉ប់រងសុខភាពរបស់អនក ឬរបាក់ជំនួយេចញៃថល ។ អន កមានសិទធិទទួ លព័ត៌មានេនះ និងជំនួយេនៅកនុងភាសារបស់អនកេដាយមិនអស លុយេឡើយ។ សូ មទូ រស័ពទ 800-722-1471 (TTY: 800-842-5357)។ ਪੰ ਜਾਬੀ (Punjabi): ਇਸ ਨੋਿਟਸ ਿਵਚ ਖਾਸ ਜਾਣਕਾਰੀ ਹੈ. ਇਸ ਨੋਿਟਸ ਿਵਚ Premera Blue Cross ਵਲ ਤੁਹਾਡੀ ਕਵਰੇਜ ਅਤੇ ਅਰਜੀ ਬਾਰੇ ਮਹੱ ਤਵਪੂਰਨ ਜਾਣਕਾਰੀ ਹੋ ਸਕਦੀ ਹੈ . ਇਸ ਨੋਿਜਸ ਜਵਚ ਖਾਸ ਤਾਰੀਖਾ ਹੋ ਸਕਦੀਆਂ ਹਨ. ਜੇਕਰ ਤੁਸੀ ਜਸਹਤ ਕਵਰੇਜ ਿਰੱ ਖਣੀ ਹੋਵੇ ਜਾ ਓਸ ਦੀ ਲਾਗਤ ਜਿਵੱ ਚ ਮਦਦ ਦੇ ਇਛੁੱ ਕ ਹੋ ਤਾਂ ਤੁਹਾਨੂੰ ਅੰ ਤਮ ਤਾਰੀਖ਼ ਤ ਪਿਹਲਾਂ ਕੁੱ ਝ ਖਾਸ ਕਦਮ ਚੁੱ ਕਣ ਦੀ ਲੋ ੜ ਹੋ ਸਕਦੀ ਹੈ ,ਤੁਹਾਨੂੰ ਮੁਫ਼ਤ ਿਵੱ ਚ ਤੇ ਆਪਣੀ ਭਾਸ਼ਾ ਿਵੱ ਚ ਜਾਣਕਾਰੀ ਅਤੇ ਮਦਦ ਪ੍ਰਾਪਤ ਕਰਨ ਦਾ ਅਿਧਕਾਰ ਹੈ ,ਕਾਲ 800-722-1471 (TTY: 800-842-5357).

‫( فارسی‬Farsi): ‫اين اعالميه ممکن است حاوی اطالعات مھم درباره فرم‬. ‫اين اعالميه حاوی اطالعات مھم ميباشد‬ ‫ به تاريخ ھای مھم در‬.‫ باشد‬Premera Blue Cross ‫تقاضا و يا پوشش بيمه ای شما از طريق‬ ‫شما ممکن است برای حقظ پوشش بيمه تان يا کمک در پرداخت ھزينه‬. ‫اين اعالميه توجه نماييد‬ ‫شما حق‬. ‫ به تاريخ ھای مشخصی برای انجام کارھای خاصی احتياج داشته باشيد‬،‫ھای درمانی تان‬ ‫ برای کسب‬.‫اين را داريد که اين اطالعات و کمک را به زبان خود به طور رايگان دريافت نماييد‬ ‫( تماس‬800-842-5357 ‫ تماس باشماره‬TTY ‫ )کاربران‬800-722-1471 ‫اطالعات با شماره‬ .‫برقرار نماييد‬ Polskie (Polish): To ogłoszenie może zawierać ważne informacje. To ogłoszenie może zawierać ważne informacje odnośnie Państwa wniosku lub zakresu świadczeń poprzez Premera Blue Cross. Prosimy zwrócic uwagę na kluczowe daty, które mogą być zawarte w tym ogłoszeniu aby nie przekroczyć terminów w przypadku utrzymania polisy ubezpieczeniowej lub pomocy związanej z kosztami. Macie Państwo prawo do bezpłatnej informacji we własnym języku. Zadzwońcie pod 800-722-1471 (TTY: 800-842-5357). Português (Portuguese): Este aviso contém informações importantes. Este aviso poderá conter informações importantes a respeito de sua aplicação ou cobertura por meio do Premera Blue Cross. Poderão existir datas importantes neste aviso. Talvez seja necessário que você tome providências dentro de determinados prazos para manter sua cobertura de saúde ou ajuda de custos. Você tem o direito de obter esta informação e ajuda em seu idioma e sem custos. Ligue para 800-722-1471 (TTY: 800-842-5357).

Fa’asamoa (Samoan): Atonu ua iai i lenei fa’asilasilaga ni fa’amatalaga e sili ona taua e tatau ona e malamalama i ai. O lenei fa’asilasilaga o se fesoasoani e fa’amatala atili i ai i le tulaga o le polokalame, Premera Blue Cross, ua e tau fia maua atu i ai. Fa’amolemole, ia e iloilo fa’alelei i aso fa’apitoa olo’o iai i lenei fa’asilasilaga taua. Masalo o le’a iai ni feau e tatau ona e faia ao le’i aulia le aso ua ta’ua i lenei fa’asilasilaga ina ia e iai pea ma maua fesoasoani mai ai i le polokalame a le Malo olo’o e iai i ai. Olo’o iai iate oe le aia tatau e maua atu i lenei fa’asilasilaga ma lenei fa’matalaga i legagana e te malamalama i ai aunoa ma se togiga tupe. Vili atu i le telefoni 800-722-1471 (TTY: 800-842-5357). Español (Spanish): Este Aviso contiene información importante. Es posible que este aviso contenga información importante acerca de su solicitud o cobertura a través de Premera Blue Cross. Es posible que haya fechas clave en este aviso. Es posible que deba tomar alguna medida antes de determinadas fechas para mantener su cobertura médica o ayuda con los costos. Usted tiene derecho a recibir esta información y ayuda en su idioma sin costo alguno. Llame al 800-722-1471 (TTY: 800-842-5357). Tagalog (Tagalog): Ang Paunawa na ito ay naglalaman ng mahalagang impormasyon. Ang paunawa na ito ay maaaring naglalaman ng mahalagang impormasyon tungkol sa iyong aplikasyon o pagsakop sa pamamagitan ng Premera Blue Cross. Maaaring may mga mahalagang petsa dito sa paunawa. Maaring mangailangan ka na magsagawa ng hakbang sa ilang mga itinakdang panahon upang mapanatili ang iyong pagsakop sa kalusugan o tulong na walang gastos. May karapatan ka na makakuha ng ganitong impormasyon at tulong sa iyong wika ng walang gastos. Tumawag sa 800-722-1471 (TTY: 800-842-5357).

ไทย (Thai): ประกาศนี ้มีข้อมูลสําคัญ ประกาศนี ้อาจมีข้อมูลที่สําคัญเกี่ยวกับการการสมัครหรื อขอบเขตประกัน สุขภาพของคุณผ่าน Premera Blue Cross และอาจมีกําหนดการในประกาศนี ้ คุณอาจจะต้ อง ดําเนินการภายในกําหนดระยะเวลาที่แน่นอนเพื่อจะรักษาการประกันสุขภาพของคุณหรื อการช่วยเหลือที่ มีค่าใช้ จ่าย คุณมีสิทธิที่จะได้ รับข้ อมูลและความช่วยเหลือนี ้ในภาษาของคุณโดยไม่มีค่าใช้ จ่าย โทร 800-722-1471 (TTY: 800-842-5357) Український (Ukrainian): Це повідомлення містить важливу інформацію. Це повідомлення може містити важливу інформацію про Ваше звернення щодо страхувального покриття через Premera Blue Cross. Зверніть увагу на ключові дати, які можуть бути вказані у цьому повідомленні. Існує імовірність того, що Вам треба буде здійснити певні кроки у конкретні кінцеві строки для того, щоб зберегти Ваше медичне страхування або отримати фінансову допомогу. У Вас є право на отримання цієї інформації та допомоги безкоштовно на Вашій рідній мові. Дзвоніть за номером телефону 800-722-1471 (TTY: 800-842-5357). Tiếng Việt (Vietnamese): Thông báo này cung cấp thông tin quan trọng. Thông báo này có thông tin quan trọng về đơn xin tham gia hoặc hợp đồng bảo hiểm của quý vị qua chương trình Premera Blue Cross. Xin xem ngày quan trọng trong thông báo này. Quý vị có thể phải thực hiện theo thông báo đúng trong thời hạn để duy trì bảo hiểm sức khỏe hoặc được trợ giúp thêm về chi phí. Quý vị có quyền được biết thông tin này và được trợ giúp bằng ngôn ngữ của mình miễn phí. Xin gọi số 800-722-1471 (TTY: 800-842-5357).