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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 is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
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9/15/2005: Code Reference section reviewed, no changes, hyperlink http://www.isokineticsinc.westserver.net no longer valid and deleted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.
04/26/2016: Policy Guidelines updated to revise investigative definition.
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.