Cervical Traction Devices - Policy Article

**NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES**  
  
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. Information provided in this policy article relates
to determinations other than those based on Social Security Act 1862(a)(1)(A)
provisions (i.e. "reasonable and necessary").  
  
Cervical traction devices are covered under the Durable Medical Equipment
benefit (Social Security Act 1861(s)(6)). In order for a beneficiary's DME to
be eligible for reimbursement, the reasonable and necessary (R&N) requirements
set out in the related Local Coverage Determination must be met. In addition,
there are specific statutory payment policy requirements, discussed below,
that also must be met.  
  

**REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO Final Rule 1713 (84 Fed.
Reg Vol 217)  
  
** Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and
a Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and
the DME MACs provide a list of the specified codes, which is periodically
updated. The required Face-to-Face Encounter and Written Order Prior to
Delivery List is available [here](https://www.cms.gov/Research-Statistics-
Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-
Review/FacetoFaceEncounterRequirementforCertainDurableMedicalEquipment).

Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol
217) that do not meet the face-to-face encounter and WOPD requirements
specified in the LCD-related Standard Documentation Requirements Article
(A55426) will be denied as not reasonable and necessary.

If a supplier delivers an item prior to receipt of a WOPD, it will be denied
as not reasonable and necessary. If the WOPD is not obtained prior to
delivery, payment will not be made for that item even if a WOPD is
subsequently obtained by the supplier. If a similar item is subsequently
provided by an unrelated supplier who has obtained a WOPD, it will be eligible
for coverage.  
  
 **POLICY SPECIFIC DOCUMENTATION REQUIREMENTS**  
  
In addition to policy specific documentation requirements, there are general
documentation requirements that are applicable to all DMEPOS policies. These
general requirements are located in the DOCUMENTATION REQUIREMENTS section of
the LCD.  
  
Refer to the LCD-related Standard Documentation Requirements article, located
at the bottom of this Policy Article under the Related Local Coverage
Documents section for additional information regarding GENERAL DOCUMENTATION
REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed
below.  
  
 **MODIFERS**  
  
KX, GA, AND GZ MODIFIERS:  
  
Suppliers must add a KX modifier to code E0849 or E0855 only if all of the
criteria in the "Coverage Indications, Limitations and/or Medical Necessity"
section of the related LCD have been met and evidence of such is maintained in
the supplier's files. This information must be available upon request.  
  
If all of the criteria in the Coverage Indications, Limitations and/or Medical
Necessity section in the related LCD have not been met, the GA or GZ modifier
must be added to the code. When there is an expectation of a medical necessity
denial, suppliers must enter the GA modifier on the claim line if they have
obtained a properly executed Advance Beneficiary Notice (ABN) or the GZ
modifier if they have not obtained a valid ABN.  
  
Claims lines billed without a KX, GA, or GZ modifier will be rejected as
missing information.  
  
  
 **CODING GUIDELINES**  
  
Code E0855 describes cervical traction devices that provide traction on the
cervical anatomy without the use of a door or external frame or stand.
Traction may be applied by means of mandibular or occipital pressure.

Code E0856 describes a cervical traction device that may or may not use an
external frame and uses an inflatable bladder(s) to generate traction forces.

Code E0860 describes cervical traction devices that provide traction on the
cervical anatomy through a system of pulleys and rope and are attached to a
door. Traction may be applied in either the upright or supine position.

Code E0849 describes cervical traction devices that provide traction on the
cervical anatomy through the use of a free-standing frame. Traction force is
applied by means of pneumatic displacement to anatomical areas other than the
mandible (e.g., the occipital region of the skull). Devices described by code
E0849 must be capable of generating traction forces greater than 20 pounds. In
addition, code E0849 devices allow traction to be applied with alternative
vectors of force (e.g., 15 degrees of lateral neck flexion).

Suppliers should contact the Pricing, Data Analysis and Coding (PDAC)
Contractor for guidance on the correct coding of these items.