Description

Cervical traction is a medical technique that uses devices to stretch soft issue and separate boney structures, thus reducing paravertebral muscle spasms and pain.

Criteria

Cervical traction devices in the home setting may be considered medically necessary when BOTH of the following criteria are met:

• The individual has a musculoskeletal or neurologic impairment requiring cervical traction equipment; and
• The appropriate use of an in-home home cervical traction device has been demonstrated to the individual who has tolerated the selected device.

All other conditions, including atlanto-occipital dislocation injuries are considered not medically necessary.

Total payments for a rental item may not exceed its allowable purchase price, except for those items identified as life sustaining DME.

Procedure Codes

Cervical traction device with inflatable air bladder is non-covered.

Procedure Codes

Documentation Requirements

• Documentation must be available upon request.
  Documentation includes: Physician’s office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports.
• The orders for the cervical traction device must be signed and dated by the treating physician, kept on file by the supplier, and be available upon request.
• The orders must contain detailed instructions for use, including frequency and duration of use.

NOTE: Orders that only state “PRN” or “as needed” utilization estimates for frequency or use are not acceptable.

Diagnosis Codes

Covered Codes for Procedure Codes: E0840, E0849, E0850, E0855, E0860

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