Effective Date: 10/06/2010
Title: Home Traction
Revision Date: 11/01/2016
CPT Code(s): E0830, E0840, E0849, E0850, E0855, E0856, E0860, E0890, E0900
will apply to all services performed on or after the above revision date which
will become the new effective date.
services referred to in this policy that were performed before the revision
date, contact customer service for the rules that would apply.
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.
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
devices, when they are covered, are covered as rental or rent-to-own DME.
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:
has completed a 6-week course of physical therapy in the outpatient setting and
still has pain; and
has failed medical therapy (e.g., oral anti-inflammatory medications, muscle
prescribes 20 pounds or more of home cervical traction; and
Any one of
the following criteria is met:
failed a trial of over-the-door cervical traction; or
has temporomandibular joint disease which may become worse with over-the-door
cervical traction; or
has distortion of the neck or chin (e.g., radical neck dissection) making use of
a chinstrap impractical, and
has had a series of trials of this device in the outpatient setting before being
sent home with one; and
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
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
cervical traction devices are considered experimental and investigational for
all other indications.
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).
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.
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.
cervical traction has been applied widely for pain relief of neck muscle spasm
or nerve root compression. It is a technique in which a force is applied to a
part of the body to reduce paravertebral muscle spasms by stretching soft
tissues, and in certain circumstances separating facet joint surfaces or bony
structures. Additional pounds for cervical traction is usually utilized in the
hospitals or clinics for temporary use and in certain situations and under
observation with occasional imaging, making sure of not to destabilize the
spine. Studies have shown that traction must be constant so that the muscles
may tire and the strain falls on the joints. It generally takes 2 minutes of
sustained traction before the intervertebral spaces begin to widen. Forces
between 20 and 50 pounds are commonly used to achieve intervertebral separation.
traction is administered by various techniques ranging from supine mechanical
motorized cervical traction to seated cervical traction using an over-the-door
pulley support with attached weights. Duration of cervical traction can range
from a few minutes to 30 minutes, once or twice weekly to several times per
day. Anecdotal evidence suggests efficacy and safety, but there is no
documentation of efficacy of cervical traction beyond short-term pain
reduction. In general, over-the-door traction at home is limited to providing
less than 20 pounds of traction.
cervical traction devices (e.g., Hometrac, Pronex) were developed to deliver
cervical traction in the home comparable to forces applied by physical
therapists in the outpatient setting. The patient is instructed in home
traction to relieve symptoms, an exercise routine to relieve spasm and
discomfort, and to report any weaknesses, eye symptoms, and bladder or bowel
some who argue that pneumatic cervical traction should be offered as first line
therapy in preference to over-the-door cervical traction, asserting that
pneumatic cervical traction is superior to over-the-door cervical traction.
There are, however, no studies in the peer reviewed published medical literature
comparing over-the-door cervical traction with pneumatic traction devices.
Although pneumatic devices are able to provide more force than over-the-door
traction devices, there are no peer-reviewed published clinical studies proving
that clinical outcomes are improved by applying greater traction force. In
addition, the potential adverse effects of the application of large amounts of
cervical traction with pneumatic devices in the home setting have not been
sufficiently evaluated in well-designed published clinical studies. There is
also no published peer-reviewed evidence proving that pneumatic traction devices
result in less irritation, improved compliance, or improved outcomes compared to
over-the-door traction. For these reasons, the uses of pneumatic cervical
traction devices are reserved for persons with neck pain who have failed
over-the-door cervical traction.
Traction is a
widely used treatment for low back pain and it is often provided in combination
with other treatment modalities. Types of traction include mechanical traction,
manual traction (unspecific or segmental traction), auto traction,
gravity-dependent ("(anti-)gravity") traction, pneumatic traction, continuous
traction, and intermittent traction.
commonly used traction techniques are manual traction (i.e., the traction is
exerted by the therapist, using arms and/or legs of the patient), inverted
suspension (i.e., the traction is exerted by gravitational forces, through the
body weight of the patient), bed rest traction (i.e., the traction is exerted by
a pulley and weights) and motorized traction (i.e., the traction is exerted by a
motorized pulley). Lumbar traction uses a harness (with Velcro strapping) that
is put around the lower rib cage and around the iliac crest. Duration and level
of force exerted through this harness can be varied in a continuous or
The American Pain Society/American
College of Physicians` clinical practice guideline on non-pharmacological
therapies for acute and chronic low back pain (Chou and Huffman, 2007) evaluated
the benefits and harms of acupuncture, back schools, psychological therapies,
exercise therapy, functional restoration, inter-disciplinary therapy, massage,
physical therapies (interferential therapy, low-level laser therapy, lumbar
supports, shortwave diathermy, superficial heat, traction, transcutaneous
electrical nerve stimulation, and ultrasonography), spinal manipulation, and
yoga for acute or chronic low back pain (with or without leg pain). The authors
concluded that therapies with good evidence of moderate efficacy for chronic or
subacute low back pain are cognitive-behavioral therapy, exercise, spinal
manipulation, and inter-disciplinary rehabilitation. For acute low back pain,
the only therapy with good evidence of efficacy is superficial heat.
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.
Scholten-Peeters GGM, van Wijngaarden S, et al. Conservative treatments for
whiplash. Cochrane Database Syst Rev. 2007 ;( 2):CD003338.
Nilsson N, Haas M, et al. Non-invasive physical treatments for chronic/recurrent
headache. Cochrane Database Syst Rev. 2004 ;( 3):CD001878.
Gross AR, Goldsmith C; the Cervical Overview Group. Mechanical traction for
mechanical neck disorders: A systematic review. J Rehabil Med. 2006;
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.
Neck pain. In: BMJ Clinical Evidence. London, UK: BMJ Publishing Group; May
DG. Chronic neck pain: How to approach treatment. Curr Pain Headache Rep. 2007;
College of Occupational and Environmental Medicine (ACOEM). Neck and upper back
complaints. Elk Grove Village, IL: ACOEM; 2004.
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.
Gross A, Goldsmith CH, et al. Mechanical traction for neck pain with or without
radiculopathy. Cochrane Database Syst Rev. 2008 ;( 3):CD006408.
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.
WJ, Morton SC, Yu EI, et al. Spinal manipulative therapy for low back pain.
Cochrane Database Syst Rev. 2004 ;( 1):CD000447.
Panel. Philadelphia Panel evidence-based clinical practice guidelines on
selected rehabilitation interventions for low back pain. Physical Therapy. 2001;
Baxter GD, Gracey JH. The efficacy of traction for back pain: A systematic
review of randomized controlled trials. Arch Phys Med Rehabil. 2003;
Hall H. Low back pain (acute). In: BMJ Clinical Evidence. London, UK: BMJ
Publishing Group; May 2007.
Hall H. Low back pain (chronic). In: BMJ Clinical Evidence. London, UK: BMJ
Publishing Group; May 2007.
Konstantinou K, O`Dowd J. Herniated disc. In: BMJ Clinical Evidence. London, UK:
BMJ Publishing Group; July 2008.
Griffiths R, Roche J, Sahota O. Hip fracture. In: BMJ Clinical Evidence. London,
UK: BMJ Publishing Group; January 2007.
Lumbar spinal decompression with a pneumatic orthesis (Orthotrac): Preliminary
study. Acta Neurochir Suppl. 2005; 92:133-137.
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.
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.
PA, Verhagen AP, Ostelo RW, et al. Effectiveness of conservative treatments for
the lumbosacral radicular syndrome: A systematic review. Europ Spine J. 2007;
van Tulder MW, Blomberg SE, et al. Traction for low-back pain with or without
sciatica. Cochrane Database Syst Rev. 2007 ;( 2):CD003010.
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.
Application to Products
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.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.