MEDICAL POLICY

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DESCRIPTION
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RATIONALE
REFERENCES
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APPENDIX
HISTORY

Home Traction Devices: Cervical and Lumbar

Number 1.01.517*

Effective Date August 12, 2013

Revision Date(s) 08/12/13; 10/26/12; 08/24/12; 07/20/12; 07/10/12; 07/12/11; 12/14/ 2010; 11/10/09; 11/11/08; 11/13/07; 12/12/06

Replaces N/A

*Medicare has a policy

Policy

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Cervical Traction Devices

Standard cervical traction devices approved for use in the home may be considered medically necessary when the following criteria are met:

  • The patient has an orthopedic, musculoskeletal or neurological impairment that requires treatment with traction equipment.
  • There is documentation from the ordering physician that traction is needed to treat the condition and a trial of traction was beneficial.

Cervical traction devices used in the home are considered investigational for all other indications including but not limited to:

  • Acute or traumatic injury
  • Fracture
  • Infections
  • Spinal instability

Lumbar Traction Devices

Lumbar traction devices when used in the home are considered not medically necessary.

Related Policies

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7.01.551

Lumbar Spine Decompression Surgery: Discectomy, Foraminotomy, Laminotomy, Laminectomy

8.03.501

Chiropractic Services

8.03.502

Physical Medicine and Rehabilitation – Physical Therapy and Medical Massage Therapy

Policy Guidelines

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Documentation of medical necessity should include:

  • Description of the medical condition with date of onset
  • Length of time the traction equipment is needed
  • Member’s functional status
  • Physician’s statement that traction is needed to treat the condition and a trial of traction was beneficial
  • Statement that the member received training on traction device and was able to demonstrate appropriate use of the selected equipment

Note: this policy addresses cervical traction devices that are approved for home use when the member is seated or lying down and do not require an additional stand or frame. Examples are an over-the-door cervical traction device or a member operated pneumatic cervical traction device approved for home use. Soft cervical collars that can be worn when the member is walking, or bedframe attached devices are not addressed in this policy.

Description

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Traction is the use of a pulling force to treat muscle spasm or immobilize a joint. There are two main types of traction, skin or skeletal.

  • Skin traction and skeletal traction. Skin traction is a non-invasive method that involves the indirect attachment of weights to the skin, providing a counterforce. This type of traction, is preferred for conditions requiring temporary traction or light pulling force, and is usually applied in an outpatient or home setting.
  • Skeletal traction is used when greater pulling force is required or for treatment of a body part that cannot be treated by skin traction. Skeletal traction requires the placement of tongs, pins, or screws into the bone so that the traction force is applied directly to the bone. The pin or screw placement is an invasive procedure that is done in an operating room under anesthesia.

Cervical Traction Devices

Cervical traction may be used in a home setting as an alternative to or in addition to outpatient rehabilitation. The patient must receive education in the proper use of the device and how to properly apply the traction in the position of maximal pain relief and to avoid discomfort. Home traction devices include both traditional over-the-door devices (applied in a sitting position) and more advanced technologies (applied in a supine position), such as the HomeTrac® and Pronex® Pneumatic Traction Unit. Standard over-the-door traction devices are traditionally limited to delivering 20 pounds or less of traction. To prevent irritation of the temporomandibular joint (TMJ), they require appropriate fitting of the head halter and instruction on the length of time the traction should be applied at each session. The head halter fits under the chin. As force is transmitted through the chin strap to the teeth, the TMJ becomes a weight-bearing structure, potentially causing the joint to deteriorate.

More recently, devices that allow greater traction force (e.g., the HomeTrac® and Pronex® cervical traction devices) have been recommended for home use. Pronex® is a patient-controlled, pneumatic traction device that is used in a supine position. (1) The device cradles a reclining patient’s head and neck between two soft foam cushions. An air-inflated bellows between the cushions provides up to 20 pounds continuously adjustable traction. The Pronex II is a new device capable of delivering greater than 20 pounds of force. Both devices are operated by a patient-controlled, handheld pump. Manufacturers and therapists propose that these devices maintain the normal cervical lordosis resulting in uniform traction posteriorly and anteriorly across the vertebral disc, in comparison to other devices, which occlude the anterior disc space for temporary relief posteriorly.

Lumbar Traction Devices

Lumbar traction is widely used to treat low back pain, often in conjunction with other treatment modalities. The traction may be applied intermittently, using any of several methods to treat conditions of the spine, in either an outpatient setting or in a home setting. Typically these modalities are used short term. Various techniques have been reported to widen or decompress disc spaces, unload the vertebrae, decrease disc protrusion or muscle spasm, separate the vertebrae, or lengthen and stabilize the spine. The duration of the exerted force applied may be intermittent or continuous throughout a treatment session. The exact mechanism through which traction is effective is unclear, and little is known about any adverse effects it may have. Commonly used home lumbar traction devices employ a free weight and pulley system capable of holding approximately 20 pounds of sand or water as a traction force.

Several available home lumbar traction devices that are not pulley and weight systems may apply increased traction forces (greater than 20 pounds). This type of device may be indicated when use of a standard home device has been unsuccessful. The Saunders HomeTrac and Saunder STx are compact home lumbar traction devices, which manufacturers claim can apply up to 200 pounds of home traction force. Manufacturers propose that the device mimics the traction offered in a clinical setting by providing a friction-free split surface that actively moves, enabling vertebral separation by inducing a pulling force. (2) It is suggested that, when using these devices, the patient can be positioned so that the lumbar curve is in any degree of flexion, neutral or in extension. Each of these devices has both a patient-controlled pressure valve that limits the amount of force transmitted to the user and a hand-held pump for immediate release of pressure.

Scope

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Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply.

Benefit Application

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Coverage for durable medical equipment and/or physical therapy is determined according to individual or group health plan benefits. (See Scope section).

Rationale

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This policy was originally created in 2006. Since that time the policy has been reviewed and updated using MEDLINE literature searches. The most recent update with literature review covered the period of October 2012 through July 2013. Following is a summary of the key literature.

Cervical Traction Devices

A review of scientific literature reveals findings from small studies that patients with cervical radiculopathy treated conservatively with cervical traction and cervical collar experienced some pain relief.

Swezey and colleagues in 1999 studied 58 outpatients and found that over-the-door traction provided symptomatic relief in 81% of the patients with mild to moderately severe cervical spondylosis. (3)

In 2002, Oliverio et all (4) retrospectively studied the records of 81 patients with cervical radiculopathy to evaluate their response to conservative treatment with cervical traction and cervical collar. Patients were offered a conservative intervention prior to surgery. Each underwent a trial of traction that consisted of wearing a cervical collar and home-based halter cervical traction: 8 to 12 pounds, applied for 15 minutes, three times a day for 3 to 6 weeks. Sixty-three (78%) of 81 patients responded to therapeutic traction, experiencing significant or total pain relief, three could not tolerate the traction, and traction failed in 15 patients. Three of the 63 patients in whom an initial response to traction was noted suffered recurrence of symptoms and required surgery. The authors concluded that It would appear that in patients in whom symptoms of cervical radiculopathy were present for approximately 6 weeks that 75% will respond to further conservative treatment (halter traction and cervical collar) over the next 6 weeks.

In 2002, Constantoyannis and colleagues (5) reported on 4 patients with cervical radiculopathy and large-volume herniated disks experiencing neck pain radiating to an arm. After 3 weeks of treatment using intermittent on-the-door cervical traction under the supervision of a physiotherapist, patients reported complete resolution of symptoms. Only 1 patient had a recurrence of pain 16 month after the first treatment.

In 2009, Jellad et al. (6) published their prospective study of the effects intermittent mechanical and manual cervical traction in patients with recent cervical radiculopathy (CR) between April 2005 and October 2006. Patients were assigned to 3 groups of 13 each (n=39). Group A was treated with conventional rehabilitation and manual traction; Group B was treated with conventional rehabilitation and intermittent mechanical traction; Group C was treated with only conventional rehabilitation. The researchers assessed the effect of the different intervention on pain, use of analgesics and disability at baseline, at the end and 1, 3, and 6 months after treatment. The findings were that at the end of treatment cervical pain, radicular pain and disability was significantly better in groups A and B compared to group C. The decreased use of analgesics was similar in all three groups. At 6 months the improvement was still significant compared to baseline for groups A and B. The increase in use of analgesics was significant for all three groups. The authors concluded that manual or mechanical cervical traction appears to be a major contributor to rehabilitation of patients with CR when included in a multimodal approach.

In 2011, Chiu and colleagues investigated the efficacy of intermittent cervical traction in the treatment of chronic neck pain over a 12 week period. This randomized controlled trial of 79 patients who were treated in a hospital-based outpatient practice. Subjects were assigned to either an experimental group (n=39 mean age of 50.5) or a control group (n=40 mean age of 48.8). The experimental group received intermittent cervical traction and the control group received infrared irradiation alone twice a week over a period of six weeks. Outcome measurements included the Northwick Park Neck Pain Questionnaire, verbal numerical pain scale and cervical active range of motion, and were measured at baseline, six-week and 12-week follow-up. The authors concluded that there were no significant differences between the two groups. (7)

Lumbar Traction Devices

A review of the scientific literature reveals inconsistent findings regarding the effectiveness of traction in the treatment of low back pain. Most studies have been of poor methodological quality, with small sample sizes and lack of randomization. (8)

In 2003, Borman and colleagues conducted a randomized controlled study of 42 patients for the purpose of determining efficacy of traction in treatment of low back pain. (9) Patients were randomly assigned to either receive standard physical therapy or standard physical therapy with conventional lumbar traction. Standard physical therapy consisted of local heat, ultrasound to the lumbar region and an active exercise program and was provided in 10 sessions. Patients in both groups noted a significant reduction in pain intensity and disability at the end of treatment. The authors concluded that no specific effect of traction was observed in the study group.

In 2006, The Cochrane Collaboration’s stated objective was to determine if traction is more effective than reference treatments, placebo/sham traction, or no treatment for low back pain. (10)They reviewed a total of 24 randomized controlled trials (2177 patients). The authors concluded that based on the current evidence, intermittent or continuous traction as a single treatment for low back pain (LBP) could not be recommended for mixed groups of patients with LBP with and without sciatica. Neither could traction be recommended for patients with sciatica because of inconsistent results and methodological problems in most of the studies involved. However, because high-quality studies within the field are scarce, because many are underpowered, and because traction often is supplied in combination with other treatment modalities, the literature allows no firm negative conclusion that traction, in a generalized sense, is not an effective treatment for patients with LBP.

In 2011, Van Middelkoop and colleagues conducted a systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain. (11) They reviewed studies on exercise therapy, back school, transcutaneous electrical nerve stimulation (TENS), low level laser therapy, education, massage, behavioral treatment, traction, multidisciplinary treatment, lumbar supports, and heat/cold therapy and found 83 randomized trials that met their inclusion criteria. Based on the heterogeneity of the populations, interventions, and comparison groups, they concluded that there are insufficient data to draw firm conclusions on the clinical effect of back schools, low-level laser therapy, patient education, massage, traction, superficial heat/cold, and lumbar supports for chronic LBP.

Medicare National Coverage

Medicare NCD states “traction equipment: covered if patient has orthopedic impairment requiring traction equipment that prevents ambulation during the period of use. (Consider covering devices during ambulation; e.g. cervical collar, under the brace provision)”. (12)

Clinical Trials

A search of the Clinicaltrials.gov website at the time of this policy update (July 2013), found an open phase III randomized controlled trial NCT01500044 (13) for evaluating the effect of mobilization and exercises for cervical radiculopathy with an estimated study completion date of July 2013.

References

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  1. Washington State Department of Labor and Industries: Technology Assessment. Pronex® and HomeTrac® Cervical Traction. Last accessed July 11, 2013.
  2. Beurskens, AJ, de Vet HC, Koke AJ et al. Efficacy of traction for nonspecific low back pain. 12-week and 6-month results of a randomized clinical trial. Spine 1997; 22(23):2756-62.
  3. Swezey RL, Swezey AM, Warner K. Efficacy of home cervical traction therapy. Am J Phys Med Rehabil. 1999; 78(1):30-2.
  4. Olivero WC, Dulebohn SC. Results of halter cervical traction for the treatment of cervical radiculopathy: retrospective review of 81 patients. Neurosurg Focus 2002; 12(2):ECP1.
  5. Constantoyannis C, Konstantinou D, Kourtopoulos H et al. Intermittent cervical traction for cervical radiculopathy caused by large-volume herniated disks. J Manipulative Physiol Ther 2002; 25(3):188-92.
  6. Jellad A, Ben Salah Z, et al. The value of intermittent cervical traction in recent cervical radiculopathy. Ann Phys Rehabil Med. 2009; 52(9):638-652. Available at URL address: http://www.em-consulte.com/en/article/230963. Last accessed July 12, 2013.
  7. Chiu TT, Ng JK, Walther-Zhang B, et.al. A randomized controlled trial on the efficacy of intermittent cervical traction for patients with chronic neck pain. Clin Rehabil. 2011 Mar 22. (Epub ahead of print).
  8. 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(10):1542-53.
  9. Borman P, Keskin D, Bodur H. The efficacy of lumbar traction in the management of patients with low back pain. Rheumatol Int. 2003; 23(2):82-6.
  10. Clarke, Judy MA, van Tulder, Maruits 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(4):1591-1599.
  11. van Middelkoop, M, Rubinstein, S, Kuijpers, T, et al. A systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain. Eur Spine J. 2011; 20(1): 19–39.
  12. Centers for Medicare and Medicaid Services (CMS). National Coverage Determination for Durable Medical Equipment Reference List. NCD #280.1. Effective May 5, 2005. Available at URL address: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=190&ncdver=2&DocID=280.1&bc=gAAAAAgAAAAA&. Last accessed July 11, 2013.
  13. Langevin P, Roy J-S, Desmeules F. Cervical radiculopathy: Study protocol of a randomized trial evaluating the effect of mobilization and exercises targeting the opening of intervertebral foramen [NCT01500044]. BMC Musculoskeletal Disord. 2012, 13:10. Available at URL address: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3299659/. Last accessed July 11, 2013.

Coding

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Codes

Number

Description

CPT

   

ICD-9 Procedure

   

ICD-9 Diagnosis

721.0

Cervical spondylosis without myelopathy

 

721.1

Cervical spondylosis with myelopathy

 

722.10

Displacement of lumbar intervertebral disc without myelopathy

 

722.52

Degeneration of lumbar or lumbosacral intervertebral disc

 

723.1

Cervicalgia

 

724.02

Spinal stenosis of lumbar region

 

724.2

Lumbago

ICD-10 CM
(effective 10/01/14)

   

ICD-10-PCS
(effective 10/01/14)

   

HCPCS

E0830

Ambulatory traction device, all types, each

 

E0840

Traction frame, attached to headboard, cervical traction

 

E0849

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

 

E0850

Traction stand, freestanding, cervical traction

 

E0855

Cervical traction equipment not requiring additional stand or frame

 

E0856

Cervical traction device, cervical collar with inflatable air bladder

 

E0860

Traction equipment, overdoor, cervical

 

E0941

Gravity assisted traction device, any type

 

E0942

Cervical head harness/halter

 

E0944

Pelvic belt/harness/boot

Type of Service

Outpatient

 

Place of Service

Home

 

Appendix

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N/A

History

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Date

Reason

12/13/05

Add to Durable Medical Equipment Section - New Policy

05/26/06

Update Scope and Disclaimer - No other changes.

12/12/06

Replace Policy - Policy updated with literature review; references added. Policy reviewed by local orthopedic surgeon. Policy statement unchanged. Codes updated.

11/13/07

Replace Policy - Policy updated with literature review; no change in policy statement.

11/27/07

Codes Updated - HCPCS code E0856 added. No other changes.

11/11/08

Replace Policy - Policy updated with literature search; no change to the policy statement.

11/10/09

Replace Policy - Policy updated with literature search; no change to the policy statement.

03/09/10

Code added - No other changes.

12/14/10

Replace Policy - Policy updated with literature search; no change to the policy statement.

07/12/11

Replace Policy - Policy updated with literature search. Reference added. Home setting added to policy statement “There is documented evidence that use of traction is of benefit when delivered in an office or home setting.” Code E0830 added to policy.

07/20/12

Replace policy. Policy updated with literature search. Reference added. Policy statement revised to clarify that cervical traction devices used in the home are considered investigational for all other indications not specified.

08/24/12

Update Coding Section – ICD-10 codes are now effective 10/01/2014.

10/26/12

Update Related Policies. Title for 8.03.502 has been changed to say “Medical Massage Therapy”.

08/12/13

Replace Policy. Policy statement revised for clarity with addition of documentation that a trial of traction was beneficial. Policy guidelines added with suggested documentation to support medical necessity. Rationale section split into cervical and lumbar traction. Updates added based on a literature review through June 2013. References 6, 12, 13 added; others renumbered/removed. Policy statements revised as noted, intent is unchanged.

01/21/14

Update Related Policies. Add 7.01.551.


Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA).
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