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Home Cervical Traction Therapy

Section: Durable Medical Equipment
Effective Date: September 01, 2019
Revised Date: August 02, 2019

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

E0840    E0849    E0850    E0855    E0860

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

Procedure Codes

E0856   

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

M47.012 M47.022 M47.12 M47.22 M47.812 M47.892 M48.02
M50.00 M50.01 M50.03 M50.11 M50.020 M50.021 M50.022
M50.023 M50.120 M50.121 M50.122 M50.123 M50.221 M50.222
M50.223 M50.321 M50.322 M50.323 M50.821 M50.822 M50.823
M50.920 M50.921 M50.922 M50.923 M50.20 M50.21 M50.22
M50.30 M50.31 M50.32 M50.80 M50.81 M50.82 M50.90
M50.91 M53.0 M53.1 M53.82 M54.12 M54.2 M62.411
M62.412 M96.1 M99.11 M99.21 M99.31 M99.41 M99.51
M99.61 M99.71 S13.0XXA S13.100A S13.110A S13.111A S13.101A
S13.120A S13.121A S13.130A S13.131A S13.140A S13.141A S13.150A
S13.151A S13.160A S13.161A S13.170A S13.171A S13.180A S13.181A
S13.20XA S13.29XA S13.4XXA S13.8XXA S13.9XXA S16.1XXA M43.02
M43.03 M43.12 M43.13 M43.5X2 M43.5X3 M47.23 M47.893
M48.03 M48.8X2 M48.8X3 M50.10 M50.13 M54.13 M54.89
S13.120D S13.120S S13.121D S13.121S S13.130D S13.130S S13.131D
S13.131S S13.140D S13.140S S13.141D S13.141S S13.150D S13.150S
S13.151D S13.151S S13.160D S13.160S S13.161D S13.161S S13.170D
S13.170S S13.171D S13.171S S13.180D S13.180S S13.181D S13.181S
S16.1XXD S16.1XXS

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