E0830 — Ambulatory traction device, all types, each
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- No specific documentation requirements for home traction therapy are stated in the policy.
- Policy instruction: "When deciding coverage, the member specific benefit plan document must be referenced as the terms of the member specific benefit plan may differ from the standard plan. In the event of a conflict, the member specific benefit plan document governs."
- Policy instruction: "Before using this policy, please check the member specific benefit plan document and any applicable federal or state mandates."
- Physician prescription/order for back school or physical therapy program (program must be prescribed by the member's doctor).
Key Coverage Criteria
- None. (Policy conclusion: Home traction therapy is unproven and not medically necessary for treating low back and neck disorders with or without radiculopathy.)
- Exact policy statement: "Home traction therapy is unproven and not medically necessary for treating low back and neck disorders with or without radiculopathy due to insufficient evidence of efficacy."
- Covered ICD-10 diagnosis range for these interventions: "M54.00 - M54.9 Dorsalgia."
- Back school is medically necessary for the treatment of persons with chronic or recurrent back pain when prescribed by the member’s doctor and the program is conducted by a physical therapist or other appropriate recognized healthcare professional.
- Isokinetic devices (e.g., Biodex, Cybex, Kin-Com) and other exercise and testing machines (e.g., Isostation B-2000 and MedX) are considered acceptable alternatives for provision of medically necessary exercise in physical therapy (can be used for muscle testing and/or administering exercise therapy).
- Therapeutic procedures and manual therapy CPT codes (97110, 97140) are covered when criteria are met.
6 Active Policies
CIGNA-CPG265 — Home Traction Devices - Cervical and Lumbar - (CPG265)
AETNA-CPB-0232 — Back Pain - Non Invasive Treatments
AETNA-CPB-0569 — Lumbar Traction Devices
UHC-POL-home-traction-therapy — Home Traction Therapy
UMR-POL-UMR-home-traction-therapy — Home Traction Therapy
Related Codes
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