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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that 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. 
 
The purpose of a Local Coverage Determination (LCD) is to provide information regarding reasonable and 
necessary criteria based on Social Security Act  1862(a)(1)(A) provisions. 
 
In addition to the reasonable and necessary criteria contained in this LCD there are other payment rules, 
which are discussed in the following documents, that must also be met prior to Medicare reimbursement: 
 The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy 
under the Related Local Coverage Documents section. 
 The LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage 
Documents section. 
 Refer to the Supplier Manual for additional information on documentation requirements. 
 Refer to the DME MAC web sites for additional bulletin articles and other publications related to this 
LCD. 
 
For the items addressed in this LCD, the reasonable and necessary criteria, based on Social Security Act  
1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical 
necessity. 
 Cervical traction devices (E0840, E0849, E0850, E0855 and E0860) are covered only if both of the following 
criteria are met: 
1. The beneficiary 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 beneficiary and the 
beneficiary tolerated the selected device. 
If criteria 1 and 2 are not met, cervical traction will be denied as not reasonable and necessary. 
 
Cervical traction devices described by code E0849 or E0855 are covered only when criteria 1 and 2 above and 
either criterion A, B or C below has been met: 
A. The beneficiary has a diagnosis of temporomandibular joint (TMJ) dysfunction; and has received 
treatment for the TMJ condition; or, 
B. The beneficiary 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 practitioner 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, they will 
be denied as not reasonable and necessary. 
 
You can find this rule at the Medicare Local Coverage Determination (LCD) L33823: Cervical Traction 
Devices. 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.