Medicare Advantage

Medical Policy

Notification

Cervical Traction Devices for In-home Use

Notification Issued Date:

This AmeriHealth New Jersey Medicare Advantage policy will become effective 01/01/2024.

Title:

Cervical Traction Devices for In-home Use

Policy #:

MA05.009b

Policy

MEDICALLY NECESSARY

Cervical traction applied using a mechanical device in the home setting is considered medically necessary and, therefore, covered when all of the following criteria are met:

The individual has a musculoskeletal or neurologic impairment requiring cervical traction equipment.
The appropriate use of an in-home cervical traction device has been demonstrated to the individual who has tolerated the selected device.
The traction device will require the individual to be nonambulatory during the period of use.

Cervical traction applied using a pneumatic device in the home setting is considered medically necessary and, therefore, covered when all of the above criteria for the mechanical device are met and at least one of the following criteria is met:

The individual has a diagnosis of temporomandibular joint (TMJ) dysfunction; and has received treatment for the TMJ condition that may worsen with the use of mechanical traction
Distortion of the lower jaw or neck anatomy (e.g., radical neck dissection) such that a mechanical cervical traction device or chin halter is unable to be utilized
The treating professional provider orders and/or documents the medical necessity for greater than 20 pounds of cervical traction in the home setting.

NOT MEDICALLY NECESSARY

Cervical traction applied via attachment to a headboard or a free-standing frame has no proven clinical advantage compared to cervical traction applied via an over-the-door mechanism. Therefore, cervical traction devices applied via attachment to a headboard or a free-standing frame are considered not medically necessary and, therefore, not covered.

Inflatable cervical traction devices are considered not medically necessary and, therefore, not covered because the device does not require the individual to be nonambulatory during the period of use.

REQUIRED DOCUMENTATION

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports. This policy is consistent with Medicare's documentation requirements, including the following required documentation:

PRESCRIPTION (ORDER) STANDARD WRITTEN ORDER REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete standard written order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective standard written order at the time of an audit or after an audit for submission as an original standard written order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY REQUIREMENTS
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the durable medical equipment (DME) supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES (WHEN APPLICABLE)
The DME supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately 7 days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual’s medical record. Delivery of the supplies should not be done earlier than approximately 5 days before the individual would exhaust their on-hand supply.

Documentation of a face-to-face encounter, between the treating professional provider and the individual meeting the above requirements, including an assessment of the individual’s clinical condition supporting the need for the prescribed DME item(s), must be provided to and kept on file by the DME supplier.

If required documentation is not available on file to support a claim at the time of an audit or record request, the DME supplier may be required to reimburse the Company for overpayments.

Guidelines

The cervical traction devices described in this policy are appropriate for use in the home because they do not require supervision by a trained professional after initial set-up and instruction. These in-home devices are not to be confused with traction units, which are designed specifically for facility use and require attendance by a trained professional.

This policy is consistent with Medicare's coverage determination. The Company's reimbursement methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, in-home cervical traction is covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in the policy are met. However, services that are identified in this policy as not medically necessary are not eligible for coverage or reimbursement by the Company.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

The FDA has approved several types of in-home cervical traction devices and considers them to be Class I devices, which are exempt from premarket notification procedures.

Description

Acute neck pain is a relatively common disorder. Neck pain may be a result of, but is not limited to, sprains or strains of cervical tissues, poor posture, cervical spondylosis (degeneration of the spinal column), or cervical disc herniations with radiculopathy (pain, numbness, or weakness radiating from the spine). The pain is typically self-limiting and usually resolves spontaneously after a period of rest without sequelae. Some individuals may experience persistent pain that can be associated with numbness, tingling, muscle weakness, and loss of reflexes. Treatment for such pain may be medical or surgical and usually depends on the source of the pain.

Nonsurgical treatments aimed at relieving pain and restoring motion can include education on how to improve posture and ergonomics, oral medications, soft cervical collars, physical therapy, and cervical traction. Cervical traction is commonly performed to relieve muscle spasms in the neck and shoulders, and to relieve the pain of pinched nerves in the neck. It can be administered by various techniques ranging from supine mechanical motorized or pneumatic traction, to seated traction using over-the-door pulleys with attached weights. Cervical traction equipment is used for individuals with orthopedic impairments who require traction that prevents ambulation during the period of use.

A mechanical cervical traction unit is a device that is used to apply a therapeutic pulling force (static or intermittent) to the cervical spine. Aside from pulleys and weights, these units generally consist of a traction cord, spreader bar, heavy-duty pulley arm, door bracket, and head halter. In general, over-the-door traction is limited to providing less than 20 pounds of traction.

There are several pneumatic in-home cervical traction devices on the market, including the

Pronex® pneumatic cervical traction device (

Empi, St. Paul, MN) and the Saunders®

Hometrac device (

Empi, St. Paul, MN). According to the manufacturer's literature, these devices are used in the supine position and utilize individual-controlled air inflation to provide adjustable traction comparable to the forces provided by a physical therapist in the outpatient setting. The

Pronex® device cradles the individual's head and neck on two cushions. One cushion supports the occiput, and the other rests against the upper trapezius. When the individual inflates the device, the bellow expands and lifts the head upward. The Saunders®

Hometrac device involves resting the individual's head on a padded track. The occiput is supported by a cushion, and the forehead is held in place by a strap. When the device is pumped with air, the track expands to lift the head upward, providing up to 50 pounds of adjustable traction.

Some cervical traction devices can be used with ambulation, such as the

Pneu-trac® Traction Collar (

Trulife, Jackson, MI). According to the manufacturer, the collar's pressure can be inflated by the individual to fit diagnosis and tolerance. The flexible cervical collar is composed of a tubular, air-inflatable bladder that is secured to the collar. The bladder is filled with air, under pressure from a manually operated air pump, to inflate the bladder so that it presses downwardly against the shoulder region of the individual and continuously around the lower neck region. This expands the height of the collar, applying upward force around the base of the chin, and the left and right mandibular and occipital region of the individual. The collar allows a controlled and uniform amount of traction force to encircle the cervical region of the individual. The goal of the cervical collar is to control the amount of static traction around the neck while allowing the individual to be ambulatory.

Clinical Biomechanics of Posture® (CBP®), formerly known as Chiropractic Biophysics®, are techniques involving full spine and pelvis corrective and rehabilitative procedures. The focus of the correction is on the abnormal curvature of the spine. The technique uses cervical traction combined with spinal manipulation to improve the appearance of an abnormal-looking spine, while using radiograph studies to compare the spinal structure before and after the treatment. The goal of CBP is to relieve cervical pain, with the main focus on optimal posture and spinal alignment and correction.

References

Centers for Medicare & Medicaid Services (CMS). Federal Register. Medicare Program; Updates to Face-to-Face Encounter and Written Order Prior to Delivery List [Federal Register Web site]. 01/17/2023. Available at: https://www.cms.gov/files/document/required-face-face-encounter-and-written-order-prior-delivery-list.pdf. Accessed November 13, 2024.

Centers for Medicare & Medicaid Services (CMS). MLN Matters. Detailed written orders and face-to-face encounters. [CMS Web site]. 07/01/2013. Available at:
https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Downloads/DetailedWrittenOrdersandFacetoFaceEncounters.pdf. Accessed November 13, 2024.

Chiropractic Biophysics Online. Traction Devices. [Chiropractic Biophysics Web site]. 2022. Available at: http://www.idealspine.com/. Accessed November 13, 2024.

Harrison DE, Harrison DD, Betz JJ, et al. Increasing the cervical lordosis with chiropractic biophysics seated combined extension-compression and transverse load cervical traction with cervical manipulation: nonrandomized clinical control trial (abstract). J Manipulative Physiol Ther. 2005;26(3):214.

Noridian Healthcare Solutions. Local Coverage Article (A52476). Cervical Traction Devices. [Noridian Web site]. Original 10/01/2015. (Revised:04/07/2022). Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=52476&ver=27&bc=0. Accessed November 13, 2024.

Noridian Healthcare Solutions. Local Coverage Determination (L33823). Cervical Traction Devices. [Noridian Web site]. Original 10/01/2015. (Revised: 01/01/2020). Available at:
https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=33823. Accessed November 13, 2024.

Coding

CPT Procedure Code Number(s)

N/A

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

N/A

HCPCS Level II Code Number(s)

MEDICALLY NECESSARY

E0849 Traction equipment, cervical, free-standing stand/frame, pneumatic, applying traction force to other than mandible

E0855 Cervical traction equipment not requiring additional stand or frame

E0860 Traction equipment, overdoor, cervical

NOT MEDICALLY NECESSARY

E0840 Traction frame, attached to headboard, cervical traction

E0850 Traction stand, freestanding, cervical traction

E0856 Cervical traction device, with inflatable air bladder(s)

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From MA05.009b:

01/06/2024

This policy has been reviewed and updated without changes to intent to communicate the Company’s continuing position on cervical traction for in-home use.

Revisions From MA05.009a:

01/01/2024	Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.
03/22/2023	The policy has been reviewed and reissued to communicate the Company’s continuing position on cervical traction for in-home use.
04/06/2022	This policy has been reissued in accordance with the Company's annual review process.
11/17/2021	This policy has been reissued in accordance with the Company's annual review process.
11/09/2020	This version of the policy will become effective 11/09/2020. In accordance with the Centers for Medicare & Medicaid Services' (CMS) Final Rule 1713 (84 Fed. Reg Vol 217), a face-to-face encounter has been removed for specified HCPCS codes: E0849 TRACTION EQUIPMENT, CERVICAL, FREE-STANDING STAND/FRAME, PNEUMATIC, APPLYING TRACTION FORCE TO OTHER THAN MANDIBLE E0855 CERVICAL TRACTION EQUIPMENT NOT REQUIRING ADDITIONAL STAND OR FRAME

Revisions From MA05.009:

06/05/2019

The policy has been reviewed and reissued to communicate the Company’s continuing position on cervical traction for in-home use.

03/14/2018	The policy has been reviewed and reissued to communicate the Company’s continuing position on cervical traction for in-home use.
02/15/2017	The policy has been reviewed and reissued to communicate the Company’s continuing position on cervical traction for in-home use.
03/16/2016	The policy has been reviewed and reissued to communicate the Company’s continuing position on cervical traction for in-home use.
01/07/2015	The policy has been reviewed and reissued to communicate the Company’s continuing position on cervical traction for in-home use.
01/01/2015	This is a new policy.

Version Effective Date:

12/30/2024

Version Issued Date:

12/30/2024

Version Reissued Date: