Anthem Blue Cross Connecticut CG-DME-05 Cervical Traction Devices for Home Use Form
This procedure is not covered
This document addresses the different devices used in the home for cervical traction, including “over-the-door” and pneumatic devices.
Intermittent cervical traction is an accepted technology for treatment of a variety of musculoskeletal disorders of the neck, including but not limited to neck muscle spasm (such as whiplash), radiculopathy, discogenic pain and degenerative changes.
Clinical Indications
Medically Necessary:
An “over the door” home cervical traction device is considered medically necessary provided both of the criteria below are met:
- The individual has a musculoskeletal or neurologic impairment requiring traction equipment; and
- The appropriate use of a home cervical traction device has been demonstrated to the individual and that individual is able to tolerate the selected device.
Not Medically Necessary:
Other designs of home cervical traction units, including but not limited to, pneumatic devices, frames attached to headboards, or freestanding units are considered not medically necessary.
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