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Date Printed: June 26, 2017: 11:44 AM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

09-E0000-40

Original Effective Date: 08/15/02

Reviewed: 08/23/12

Revised: 01/01/15

Subject: Spinal Unloading Devices and Ambulatory, Inflatable, or Pneumatic Traction Devices

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
Other References Updates  

DESCRIPTION:

Spinal unloading devices are used as a conservative treatment in the home for the treatment of low back pain. These devices are patient-operated and are used for individuals who have not responded to standard medical therapy or who have failed surgical therapy. These devices provide a traction-like effect in an effort to shift weightbearing off the lower back and onto the hips. The method used to shift weightbearing varies from device to device. Some devices (e.g., LTX 3000™) utilize gravitational force provided by the body mass of the individual. Other devices (e.g., Orthotrac Pneumatic Vest™, STx™ Saunders Lumbar Traction Device, Saunders Lumbar Hometrac™ Deluxe) utilize applied pneumatic pressure in an effort to shift weightbearing.

Various types of cervical traction devices are typically used for the treatment of pain associated with muscle spasm or nerve root compression. While these various types of devices include standard over-the-door traction, this guideline discusses the use of pneumatic cervical traction devices. Examples of these devices include the Pronex® Pneumatic Traction device and The HomeTrac™ devices.

POSITION STATEMENT:

The following traction devices are considered experimental or investigational:

A literature search did not identify randomized placebo-controlled studies that have been published in the peer-reviewed medical literature, supporting safety and efficacy regarding these devices or added benefit over standard traction devices.

These devices are FDA-classified as Class I devices, which does not require submission of clinical data regarding efficacy.

BILLING/CODING INFORMATION:

HCPCS Coding:

E0830

Ambulatory traction device, all types, each (investigational)

E0849

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

E0856

Cervical traction device, with inflatable air bladder(s) (investigational)

E0941

Gravity assisted traction device, any type (this code is sometimes used to report a spinal unloading traction device)

REIMBURSEMENT INFORMATION:

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following Durable Medical Equipment Regional Carrier (DMERC) Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Cervical Traction Devices (L15905) located at cgsmedicare.com.

DEFINITIONS:

No guideline-specific definitions apply.

RELATED GUIDELINES:

None applicable.

OTHER:

Other names used to report spinal unloading devices:

Note: The use of specific product names is illustrative only. It is not intended to be a recommendation of
one product over another, and is not intended to represent a complete listing of all products available.

Back Brace
Back Bubble®
HomeTrac™
Lo-Bak (non-powered, non-invasive orthopedic traction device)

LTX 3000 Lumbar Rehabilitation System™
Lumbar spinal decompression Orthotrac Pneumatic Vest™
Saunders Cervical HomeTrac™
Spinal Unloading Devices
STx Saunders Lumbar Traction Device™
Saunders Lumbar HomeTrac™ Deluxe
Other devices defined as “thoracic-lumbo-sacral orthosis (with pneumatics)” or “pneumatic orthosis”

REFERENCES:

  1. Blue Cross Blue Shield Association Medical Policy 1.04.02 Thoracic-Lumbo Sacral Orthosis with Pneumatics, (11/10/11).
  2. Braddock EJ, Greenlee J, Hammer RE, Johnson SF, Martello MJ, O'Connell MR, Rinzler R, Snider M, Swanson MR, Tain L, Walsh G. Manual medicine guidelines for musculoskeletal injuries. Sonora (CA): Academy for Chiropractic Education; 05/01/09. 64 p. (National Guideline Clearinghouse).
  3. Chou R, Qaseem A, et al. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2 October 2007;147(7):478-491.
  4. Clarke JA, van Tulder MW, Blomberg SEI, de Vet HCW, van der Heijden GJMG, Bronfort G. Traction for low-back pain with or without sciatica. Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD003010. DOI: 10.1002/14651858.CD003010.pub3.
  5. ClinicalTrials.gov, A Randomized Controlled Trial of Treatment for Disc Herniation with Radiating Leg Pain, (accessed 03/04/07).
  6. Dallolio V. “Lumbar spinal decompression with a pneumatic orthesis (Orthotrac); preliminary study”. Acta Neurochi Suppl 2005; 92: 133-7.
  7. ECRI Hotline Response; “Home Traction Devices for Treatment of Spinal Disorders and Pain”, (08/27/07).
  8. ECRI Hotline Response; “Orthotrac Pneumatic Vest for Back Pain”, (11/09/05).
  9. Ferrara L, Triano JJ, Sohn MJ, Song E, Lee DD. A biomechanical assessment of disc pressures in the lumbosacral spine in response to external unloading forces. Spine J. 2005 Sep-Oct; 5(5): 548-53.
  10. Hayes Directory of Technology Assessment-Spinal Unloading Devices For Low Back Pain, (09/14/01; updated 08/09/06; archived 2007).
  11. International Chiropractors Association of California. Management of whiplash associated disorders. Sacramento (CA): International Chiropractors Association of California; 2009. 55 p. (National Guideline Clearinghouse).
  12. Medicare Region C DMERC (CIGNA Government Services) Article A18074 for Cervical Traction Devices, (08/05/11)
  13. Medicare Region C DMERC (CIGNA Government Services) Local Coverage Determination L15905 Cervical Traction Devices, (08/05/11).
  14. North American Spine Society. Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care. Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders (2010).

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 08/23/12.

GUIDELINE UPDATE INFORMATION:

08/15/02

New Medical Coverage Guideline.

08/15/03

Reviewed; no change in investigational status.

04/01/04

HCPCS coding update (added E0830).

07/15/04

Scheduled review; no changes.

05/15/05

Unscheduled review with revision consisting of addition of statement addressing all spinal unloading traction devices; MCG name change.

05/15/06

Scheduled review; no change in coverage statement.

05/15/07

Scheduled review; revised MCG title; reformatted guideline; added position statement for inflatable lumbar traction devices; expanded rationale; added HCPCS codes E0849 and E0941; added Program Exception for Medicare Advantage products.

05/15/08

Scheduled review; no change in position statement, references updated.

05/15/09

Scheduled review; no change in position statement; references updated.

06/15/10

Review of position statement regarding pneumatic traction devices; position statement unchanged; references updated.

09/15/12

Review of position statement; position statement updated; references updated.

05/15/14

Revision; Program Exceptions section updated.

01/01/15

Annual coding update; revised E0856.

Date Printed: June 26, 2017: 11:44 AM