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LCD
ID Number
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L15844
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LCD
Title
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Cervical Traction Devices
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Contractor's
Determination Number
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CTD20080101
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AMA
CPT / ADA
CDT Copyright Statement
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CPT codes, descriptions and other data only are copyright 2007
American Medical Association (or such other date of publication of CPT).
All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental
Terminology, (CDT) (including procedure codes, nomenclature, descriptors
and other data contained therein) is copyright by the American Dental
Association. © 2002, 2004 American Dental Association. All rights reserved.
Applicable FARS/DFARS apply.
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CMS
National Coverage Policy
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CMS Pub. 100-3, Medicare National Coverage Determinations Manual,
Chapter 1, Section 280.1
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Primary Geographic
Jurisdiction
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Connecticut
District of Columbia
Delaware
Massachusetts
Maryland
Maine
New Hampshire
New Jersey
New York - Entire State
Pennsylvania
Rhode Island
Vermont
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Oversight
Region
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Region III
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Original
Determination Effective Date
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For services performed on or after 07/01/2004
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Original
Determination Ending Date
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Revision
Effective Date
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For services performed on or after 01/01/2008
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Revision
Ending Date
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Indications
and Limitations of Coverage and/or Medical Necessity
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For any item to be covered by Medicare, it must 1) be eligible for
a defined Medicare benefit category, 2) be reasonable and necessary for the
diagnosis or treatment of illness or injury or to improve the functioning
of a malformed body member, and 3) meet all other applicable Medicare
statutory and regulatory requirements. For the items addressed in this
medical policy, the criteria for "reasonable and necessary" are
defined by the following indications and limitations of coverage and/or
medical necessity.
For an item to be covered by Medicare, a written signed and dated order
must be received by the supplier before a claim is submitted. If the
supplier bills for an item addressed in this policy without first receiving
the completed order, the item will be denied as not medically necessary.
Cervical traction devices (E0840-E0860) are covered only if both of the
following criteria are met:
1. The patient has a musculoskeletal or neurologic
impairment requiring traction equipment; and,
2. The appropriate use of a home cervical traction device has been
demonstrated to the patient and the patient tolerated the selected device.
If criteria 1 and 2 are not met, cervical traction will be denied as not
medically necessary.
Cervical traction applied via attachment to a headboard (E0840) or a
free-standing frame (E0850) has no proven clinical advantage compared to
cervical traction applied via an over-the-door mechanism (E0860). If an
E0840 or E0850 is ordered and the medical necessity criteria for cervical
traction devices are met, reimbursement will be based on the allowance for
the least costly medically appropriate alternative (E0860).
Cervical traction devices described by code E0849 or E0855 are covered only
when criteria 1 and 2 above and either criteria A, B or C below have been
met:
A. The patient has a diagnosis of temporomandibular
joint (TMJ) dysfunction; and has received treatment for the TMJ condition;
or,
B. The patient has distortion of the lower jaw or neck anatomy (e.g.,
radical neck dissection) such that a chin halter is unable to be utilized;
or,
C. The treating physician orders and/or documents the medical necessity for
greater than 20 pounds of cervical traction in the home setting.
If the criteria for cervical traction are met but the additional criteria
for E0849 or E0855 are not met, reimbursement will be based on the
allowance for the least costly medically appropriate alternative (E0860).
E0856 describes a cervical traction device that can be used with
ambulation. Therefore, it will be denied as not medically necessary.
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Coverage
Topic
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Durable Medical Equipment
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