Anthem Blue Cross Connecticut CG-DME-05 Cervical Traction Devices for Home Use Form

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.