Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Auto traction devices, axial spinal unloading devices, and pneumatic lumbar traction devices are not covered, as these devices have not been shown to be effective for back pain or other indications.

2)    Cervical traction devices may be covered.  Most patients requiring home cervical traction are adequately treated with use of over the door traction, and do not need pneumatic devices.

3)    Home traction devices, when they are covered, are covered as rental or rent-to-own DME.

1.     Pneumatic cervical traction devices for home use is considered medically necessary durable medical equipment (DME) to alleviate pain caused by paravertebral muscle spasm when all of the following criteria are met: 

A.    The member has completed a 6-week course of physical therapy in the outpatient setting and still has pain; and

B.    The member has failed medical therapy (e.g., oral anti-inflammatory medications, muscle relaxants); and

C.    The doctor prescribes 20 pounds or more of home cervical traction; and

D.    Any one of the following criteria is met:

i.       The member failed a trial of over-the-door cervical traction; or

ii.      The member has temporomandibular joint disease which may become worse with over-the-door cervical traction; or

iii.    The member has distortion of the neck or chin (e.g., radical neck dissection) making use of a chinstrap impractical, and

E.    The member has had a series of trials of this device in the outpatient setting before being sent home with one; and

F.    Home therapy is being supervised by a physical therapist

Codes Used In This BI:

E0830 Ambulatory traction device, all types, each
E0840 Traction frame, attached to headboard, cervical traction
E0849
Traction equipment, cervical, freestanding stand/frame, pneumatic, applying traction force to other than mandible
E0850 Traction stand, freestanding, cervical traction
E0855 Cervical traction equipment not requiring addtl stand or frame
E0856 Cervical traction device, w/inflatable air bladder(s)
E0860 Traction equipment, overdoor, cervical
E0870 Traction frame, attached to footboard, extremity traction
E0880 Traction stand, freestanding, extremity traction
E0890 Traction frame, attached to footboard, pelvic traction
E0900 Traction stand, freestanding, pelvic traction
 

1.     Pneumatic cervical traction devices are considered experimental and investigational for all other indications.

2.     Auto traction devices are considered experimental and investigational because there is insufficient evidence to support their clinical value in treating low back pain or for other indications. (Brand names of auto traction devices include the Spinalator Spinalign massage intersegmental traction table, the Arthrotonic stabilizer, the Quantum 400 intersegmental traction table and the Anatomotor).

3.     Home pneumatic lumbar traction devices (e.g., Saunders Lumbar HomeTrac, Saunders STx, and Orthotrac Pneumatic Vest) are considered experimental and investigational because they have not been demonstrated to be an effective treatment for low back pain or other indications.

4.     Axial spinal unloading (gravity-dependent traction) devices (e.g., LTX 3000) are considered experimental and investigational for the treatment of low back pain or other indications because their effectiveness has not been established.

1.     Washington State Department of Labor and Industries, Office of the Medical Director. Pronex and Hometrac cervical traction. Technology Assessment. Olympia, WA: Washington State Department of Labor and Industries; August 5, 2002. Available at: http://www.lni.wa.gov/omd/TechAssessDocs.htm. Accessed August 7, 2003.

2.     Verhagen AP, Scholten-Peeters GGM, van Wijngaarden S, et al. Conservative treatments for whiplash. Cochrane Database Syst Rev. 2007 ;( 2):CD003338.

3.     Bronfort G, Nilsson N, Haas M, et al. Non-invasive physical treatments for chronic/recurrent headache. Cochrane Database Syst Rev. 2004 ;( 3):CD001878.

4.     Graham N, Gross AR, Goldsmith C; the Cervical Overview Group. Mechanical traction for mechanical neck disorders: A systematic review. J Rehabil Med. 2006; 38(3):145-152.

5.     Vaughn HT, Having KM, Rogers JL. Radiographic analysis of intervertebral separation with a 0 degrees and 30 degrees rope angle using the Saunders cervical traction device. Spine. 2006; 31(2):E39-E43.

6.     Binder A. Neck pain. In: BMJ Clinical Evidence. London, UK: BMJ Publishing Group; May 2007.

7.     Borenstein DG. Chronic neck pain: How to approach treatment. Curr Pain Headache Rep. 2007; 11(6):436-439.

8.     American College of Occupational and Environmental Medicine (ACOEM). Neck and upper back complaints. Elk Grove Village, IL: ACOEM; 2004.

9.     Cleland JA, Whitman JM, Fritz JM, Palmer JA. Manual physical therapy, cervical traction, and strengthening exercises in patients with cervical radiculopathy: A case series. J Orthop Sports Phys Ther. 2005; 35(12):802-811.

10. Graham N, Gross A, Goldsmith CH, et al. Mechanical traction for neck pain with or without radiculopathy. Cochrane Database Syst Rev. 2008 ;( 3):CD006408.

11. Raney NH, Petersen EJ, Smith TA, et al. Development of a clinical prediction rule to identify patients with neck pain likely to benefit from cervical traction and exercise. Eur Spine J. 2009; 18(3):382-391.

12. Assendelft WJ, Morton SC, Yu EI, et al. Spinal manipulative therapy for low back pain. Cochrane Database Syst Rev. 2004 ;( 1):CD000447.

13. Philadelphia Panel. Philadelphia Panel evidence-based clinical practice guidelines on selected rehabilitation interventions for low back pain. Physical Therapy. 2001; 81(10):1641-1674.

14. Harte AA, Baxter GD, Gracey JH. The efficacy of traction for back pain: A systematic review of randomized controlled trials. Arch Phys Med Rehabil. 2003; 84:1542-1553.

15. McIntosh G, Hall H. Low back pain (acute). In: BMJ Clinical Evidence. London, UK: BMJ Publishing Group; May 2007.

16. McIntosh G, Hall H. Low back pain (chronic). In: BMJ Clinical Evidence. London, UK: BMJ Publishing Group; May 2007.

17. Jordan J, Konstantinou K, O`Dowd J. Herniated disc. In: BMJ Clinical Evidence. London, UK: BMJ Publishing Group; July 2008.

18. Oliver D, Griffiths R, Roche J, Sahota O. Hip fracture. In: BMJ Clinical Evidence. London, UK: BMJ Publishing Group; January 2007.

19. Dallolio V. Lumbar spinal decompression with a pneumatic orthesis (Orthotrac): Preliminary study. Acta Neurochir Suppl. 2005; 92:133-137.

20. Chromy CA, Carey MT, Balgaard KG, Iaizzo PA. The potential use of axial spinal unloading in the treatment of adolescent idiopathic scoliosis: A case series. Arch Phys Med Rehabil. 2006; 87(11):1447-1453.

21. Clarke J, Van Tulder M, Blomberg S, et al.  Traction for low back pain with or without sciatica: An updated systematic review within the framework of the Cochrane Collaboration. Spine. 2006; 31(14):1591-1599.

22. Luijsterburg PA, Verhagen AP, Ostelo RW, et al. Effectiveness of conservative treatments for the lumbosacral radicular syndrome: A systematic review. Europ Spine J. 2007; 16(7):881-899.

23. Clarke JA, van Tulder MW, Blomberg SE, et al. Traction for low-back pain with or without sciatica. Cochrane Database Syst Rev. 2007 ;( 2):CD003010.

24. Chou R, Huffman LH; American Pain Society; American College of Physicians. Nonpharmacologic therapies for acute and chronic low back pain: A review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007; 147(7):492-504.

This policy applies to all health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD, EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.