Home Cervical Traction Therapy

Policy ID: E-52-008

Section: Durable Medical Equipment

Effective Date: September 01, 2019

Revised Date: March 30, 2022

Revision Effective Date: July 07, 2025

Last Reviewed: May 13, 2025

Applies To: Commercial and Medicaid Expansion

Description

Cervical traction is a medical technique that uses devices to apply forces that are atraumatic to the cervical spine and used to treat neck pain with or without cervical radicular pain.

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

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 by a medical professional and the individual has tolerated the selected device.

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

Cervical traction devices not meeting the criteria as indicated in this policy are considered not medically necessary.

Procedure Codes

E0840

E0849

E0850

E0855

E0860

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

Procedure Code

E0856

Diagnosis Codes

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

M43.02

M43.03

M43.12

M43.13

M43.5X2

M43.5X3

M47.012

M47.022

M47.12

M47.22

M47.23

M47.812

M47.892

M47.893

M48.02

M48.03

M48.8X2

M48.8X3

M50.00

M50.01

M50.020

M50.021

M50.022

M50.023

M50.03

M50.10

M50.11

M50.120

M50.121

M50.122

M50.123

M50.13

M50.20

M50.21

M50.22

M50.221

M50.222

M50.223

M50.30

M50.31

M50.32

M50.321

M50.322

M50.323

M50.80

M50.81

M50.82

M50.821

M50.822

M50.823

M50.90

M50.91

M50.920

M50.921

M50.922

M50.923

M53.0

M53.1

M53.82

M54.12

M54.13

M54.2

M54.89

M62.411

M62.412

M96.1

M99.11

M99.21

M99.31

M99.41

M99.51

M99.61

M99.71

S13.0XXA

S13.100A

S13.101A

S13.110A

S13.111A

S13.120A

S13.120D

S13.120S

S13.121A

S13.121D

S13.121S

S13.130A

S13.130D

S13.130S

S13.131A

S13.131D

S13.131S

S13.140A

S13.140D

S13.140S

S13.141A

S13.141D

S13.141S

S13.150A

S13.150D

S13.150S

S13.151A

S13.151D

S13.151S

S13.160A

S13.160D

S13.160S

S13.161A

S13.161D

S13.161S

S13.170A

S13.170D

S13.170S

S13.171A

S13.171D

S13.171S

S13.180A

S13.180D

S13.180S

S13.181A

S13.181D

S13.181S

S13.20XA

S13.29XA

S13.4XXA

S13.8XXA

S13.9XXA

S16.1XXA

S16.1XXD

S16.1XXS

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Pre/Post Medical Review 8-10-2020 Coding update

Internal Medical Policy Committee 3-17-2021 Annual Review

Updated language

Internal Medical Policy Committee 3-23-2022 Revision

Revised language

Internal Medical Policy Committee 3-23-2023 Annual Review-no changes in criteria

Internal Medical Policy Committee 5-14-2024 Annual Review-no changes in criteria

Added Policy Application

Internal Medical Policy Committee 5-13-2025 Annual Review-no changes in criteria

Updated Policy Application

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: E-52-007

Section: Durable Medical Equipment

Effective Date: September 01, 2019

Revised Date: March 30, 2022

Revision Effective Date: May 02, 2022

Last Reviewed: March 23, 2023

Archived Date: May 12, 2025

Applies To: Commercial and Medicaid Expansion

Description

Cervical traction is a medical technique that uses devices to apply forces that are atraumatic to the cervical spine and used to treat neck pain with or without cervical radicular pain.

Policy Application

All claims submitted under this policy’s section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.

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 by a medical professional and the individual has tolerated the selected device.

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

Cervical traction devices not meeting the criteria as indicated in this policy are considered not medically necessary.

Procedure Codes

E0840

E0849

E0850

E0855

E0860

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

Procedure Codes

E0856

Diagnosis Codes

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

M43.02

M43.03

M43.12

M43.13

M43.5X2

M43.5X3

M47.012

M47.022

M47.12

M47.22

M47.23

M47.812

M47.892

M47.893

M48.02

M48.03

M48.8X2

M48.8X3

M50.00

M50.01

M50.020

M50.021

M50.022

M50.023

M50.03

M50.10

M50.11

M50.120

M50.121

M50.122

M50.123

M50.13

M50.20

M50.21

M50.22

M50.221

M50.222

M50.223

M50.30

M50.31

M50.32

M50.321

M50.322

M50.323

M50.80

M50.81

M50.82

M50.821

M50.822

M50.823

M50.90

M50.91

M50.920

M50.921

M50.922

M50.923

M53.0

M53.1

M53.82

M54.12

M54.13

M54.2

M54.89

M62.411

M62.412

M96.1

M99.11

M99.21

M99.31

M99.41

M99.51

M99.61

M99.71

S13.0XXA

S13.100A

S13.101A

S13.110A

S13.111A

S13.120A

S13.120D

S13.120S

S13.121A

S13.121D

S13.121S

S13.130A

S13.130D

S13.130S

S13.131A

S13.131D

S13.131S

S13.140A

S13.140D

S13.140S

S13.141A

S13.141D

S13.141S

S13.150A

S13.150D

S13.150S

S13.151A

S13.151D

S13.151S

S13.160A

S13.160D

S13.160S

S13.161A

S13.161D

S13.161S

S13.170A

S13.170D

S13.170S

S13.171A

S13.171D

S13.171S

S13.180A

S13.180D

S13.180S

S13.181A

S13.181D

S13.181S

S13.20XA

S13.29XA

S13.4XXA

S13.8XXA

S13.9XXA

S16.1XXA

S16.1XXD

S16.1XXS

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Pre/Post Medical Review 8-10-2020 Coding update

Internal Medical Policy Committee 3-17-2021 Annual Review - updated language

Internal Medical Policy Committee 3-23-2022 Revision

Revised language

Internal Medical Policy Committee 3-23-2023 Annual Review-no changes in criteria

Links

References (PDF)

Disclaimer

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Medical Policies Quick Search

Home Cervical Traction Therapy

Description

Policy Application

Criteria

Procedure Codes

Procedure Code

Diagnosis Codes

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

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer

Description

Policy Application

Criteria

Procedure Codes

Procedure Codes

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer