Cervical traction devices provide traction on the cervical anatomy. The traction can be applied via methods such as, but not limited to, the following: an attachment to a headboard, an over-the-door mechanism, a free-standing frame, or a means of mandibular or occipital pressure.

For any item to be covered, it must:

1. be eligible for a defined Medicare benefit category;
2. be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member; and,
3. meet all other applicable statutory and regulatory requirements.

For the items addressed in this medical policy, the criteria for "reasonable and necessary" are defined by the following indications and limitations of coverage.

For an item to be covered, a written signed and dated order must be received by the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving the completed order, the item will be denied as not medically necessary.

Cervical traction devices (E0840-E0855 and E0860) are covered only if both of the following criteria are met:

1. The patient has a musculoskeletal or neurologic impairment requiring traction equipment; and,
   
   
2. The appropriate use of a home cervical traction device has been demonstrated to the patient and the patient tolerated the selected device.

If criteria 1 and 2 are not met, cervical traction will be denied as not medically necessary.

Cervical traction applied via attachment to a headboard (E0840) or a free-standing frame (E0850) has no proven clinical advantage compared to cervical traction applied via an over-the-door mechanism (E0860). If an E0840 or E0850 is ordered and the medical necessity criteria for cervical traction devices are met, reimbursement will be based on the allowance for the least costly medically appropriate alternative (E0860).

Cervical traction devices described by code E0849 or code E0855 are covered only when criteria 1 and 2 above and either criteria A, B, or C below have been met:

1. The patient has a diagnosis of temporomandibular joint (TMJ) dysfunction and has received treatment for the TMJ condition; or,
   
   
2. The patient has distortion of the lower jaw or neck anatomy (e.g., radical neck dissection) such that a chin halter is unable to be utilized; or,
   
   
3. The treating physician orders and/or documents the medical necessity for greater than 20 pounds of cervical traction in the home setting.

If the criteria for cervical traction are met but the additional criteria for E0849 or E0855 are not met, reimbursement will be based on the allowance for the least costly medically appropriate alternative (E0860).

E0856 describes a cervical traction device that can be used with ambulation. Therefore, it will be denied as not medically necessary. 

Services that do not meet the medical necessity criteria on this policy will be considered not medically necessary. A provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

Reasons for Noncoverage

Cervical traction devices are covered under the durable medical equipment (DME) benefit. Cervical orthoses, such as soft or rigid cervical collars, are not considered DME; however, they are eligible for coverage under the Prosthetic and Orthotic benefit.

Documentation Requirements

An order 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. Items billed before a signed and dated order has been received by the supplier must be submitted with an EY modifier added to each affected procedure code.

GA, GZ and KX Modifiers
Suppliers must add a KX modifier to code E0849 or E0855 only if all of the criteria in the "Indications and Limitations of Coverage" section of this policy have been met and evidence of such is maintained in the supplier's files. This information must be available upon request.

If all of the criteria in the Indications and Limitations of Coverage section have not been met, the GA or GZ modifier must be added to the code. When there is an expectation of a medical necessity denial, suppliers must enter the GA modifier on the claim line if they have obtained a properly executed Pre-Service Denial Notice or the GZ modifier if they have not obtained a valid Pre-Service Denial Notice. Services submitted with a GA modifier will be denied as not medically necessary and are billable to the member. Services submitted with a GZ modifier will be denied as not medically necessary and are not billable to the member.

Claim lines billed without a GA, GZ or KX modifier will be rejected as missing information.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Code E0855 describes cervical traction devices that provide traction on the cervical anatomy without the use of a door or external frame or stand. Traction may be applied by means of mandibular or occipital pressure.

Code E0860 describes cervical traction devices that provide traction on the cervical anatomy through a system of pulleys and rope and are attached to a door. Traction may be applied in either the upright or supine position.

Code E0849 describes cervical traction devices that provide traction on the cervical anatomy through the use of a free-standing frame. Traction force is applied by means of pneumatic displacement to anatomical areas other than the mandible (e.g., the occipital region of the skull). Devices described by code E0849 must be capable of generating traction forces greater than 20 pounds. In addition, code E0849 devices allow traction to be applied with alternative vectors of force (e.g., 15 degrees of lateral neck flexion).

Suppliers should contact the Pricing, Data Analysis and Coding (PDAC) Contractor for guidance on the correct coding of these items. https://www.dmepdac.com/

Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider." It is expected that the patient's medical records will reflect the need for the care provided. The patient's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request.

CMS Publication 100-3, Medicare National Coverage Determinations Manual, Chapter 1, Section 280.1