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Traction applied to the cervical spine by applying force to lift the head or a mobilization technique to distract individual joints of the vertebrae is cervical traction.
Cervical traction devices are considered investigational.
Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY7/2003: Approved by Medical Policy Advisory Committee (MPAC)
12/22/2003: Code Reference section completed
3/22/2005: Code Reference section updated, HCPCS E0849 with effective date of 1/1/2005 added
6/30/2005: Code Reference section updated, HCPCS K0627 with effective date of 4/1/2004 and deletion date of 12/31/2004added
7/21/2005: Reviewed by MPAC, remains investigational, Sources updated
9/15/2005: Code Reference section reviewed, no changes, hyperlink http://www.isokineticsinc.westserver.net no longer valid and deleted
10/17/2006: Policy reviewed, no changes
12/19/2007: Coding updated per the 2008 CPT/HCPCS changes
12/31/2014: Code Reference section updated to revise the description of the following HCPCS code: E0856.
08/18/2015: Code Reference section updated for ICD-10.
SOURCE(S)Taber's Cyclopedic Medical Dictionary
Aetna policy # 0453http://www.allegromedical.com
www.empi.com (added 7-21-2005)
Empi packet (added 7-21-2005)
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.