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
- Physician prescription/order for back school or physical therapy program (program must be prescribed by the member's doctor).
- Evidence that the back school program is conducted by a physical therapist or other appropriate recognized healthcare professional.
- Documentation that isokinetic/exercise/testing machines are used as part of medically necessary physical therapy (i.e., justification that device use is integral to the course of PT and medically necessary).
- Clinical records supporting chronic or recurrent back pain diagnosis (e.g., ICD-10 dorsalgia codes M54.00–M54.9) when billing covered CPT/HCPCS codes.
Key Coverage Criteria
- 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.
- Therapeutic activities CPT code 97530 is covered when criteria are met (note: not covered when used for Khan Kinetic Treatment).
10 Active Policies
UHC-POL-home-traction-therapy, Home Traction Therapy
AETNA-CPB-0232, Back Pain - Noninvasive Treatments
AETNA-CPB-0569, Lumbar Traction Devices
BCBSIL-ADM1001.036, Medical Policies Moving to MCG Guidelines
BCBSMT-ADM1001.036, Medical Policies Moving to MCG Guidelines
Related Codes
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