RetiredCareFirstPolicy 1.01.031

Fracture / Traction Frames and Associated Equipment

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Coverage and medical necessity criteria for fracture and traction frames and associated equipment (DME) used to immobilize and align injured extremities or pelvis for CareFirst members; excludes cervical traction which is covered under a separate DME policy.

Policy Summary

PayerCareFirst

PolicyFracture / Traction Frames and Associated Equipment

Policy CodePolicy 1.01.031

Change TypeNo material change

Effective Date

Last ReviewOct 1, 2022

Next Review DateOct 1, 2022

Key ActionTreating physician must order the fracture/traction frame and medical record must document the injury and home-application safety as applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

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RetiredCareFirstPolicy 1.01.031

Fracture / Traction Frames and Associated Equipment

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Sign up for CareFirst Policy 1.01.031 alerts

Get alerted when Policy 1.01.031 changes without checking for updates manually.

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Policy Summary

PayerCareFirst

PolicyFracture / Traction Frames and Associated Equipment

Policy CodePolicy 1.01.031

Change TypeNo material change

Effective Date

Last ReviewOct 1, 2022

Next Review DateOct 1, 2022

Key ActionTreating physician must order the fracture/traction frame and medical record must document the injury and home-application safety as applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Coverage Criteria

Medical Necessity Criteria

Covered when ALL of the following are met

Medical necessity for immobilization and alignment: Fracture/traction frames and associated equipment are considered medically necessary for the immobilization and skeletal alignment of a member's injured body part to reduce pain, inflammation, and muscle spasm.

This policy does not address cervical traction. For coverage and clinical requirements related to cervical traction devices, see Durable Medical Equipment with Attached Table, Policy 1.01.001.

DME-specific Medical Necessity

DME-specific medical necessity

Covered when ALL of the following are met

Purpose: Device is used for immobilization and skeletal alignment to reduce pain, inflammation, and muscle spasm.

Ordering: The fracture/traction frame must be ordered by the member's treating physician.

Clinical documentation: Medical record documents an injury or condition affecting an extremity or the pelvis.

Home safety: If intended for home use, documentation must show the traction/fracture frame can be safely applied in the home setting.

Provider Actions & Billing

Prior Authorization

Report codes and obtain physician order

Fracture/traction frames must be reported using the listed HCPCS codes and must be ordered by the member's treating physician; supporting documentation must be present in the medical record as described by the policy.

Report with HCPCS: E0830, E0870, E0880, E0890, E0900, E0910, E0911, E0912, E0920, E0930, E0940, E0941, E0944, E0945, E0946, E0947
Device must be ordered by the member's treating physician
Medical record must support the order per policy guidelines

Note

Documentation Required

Document injury/condition and home-application safety

Documentation Requirements

Documentation Required

Obtain physician order and supporting medical record documentation

Obtain a treating physician's order and ensure the medical record contains the supporting documentation described in policy: evidence of an injury/condition affecting an extremity or the pelvis and, if applicable, that the frame can be safely applied in the home.

Have the member's treating physician place the order for the fracture/traction frame
Include documentation of the injury/condition affecting an extremity or pelvis
Include documentation that the device can be safely applied in the home when intended for home use

Reported HCPCS Codes

Reported HCPCS CodesHCPCS

E0830	E0830
E0870	E0870
E0880	E0880
E0890	E0890
E0900	E0900
E0910	E0910
E0911	E0911
E0912	E0912
E0920	E0920
E0930	E0930

1–10 of 16

1/2

Rental and Purchase Rules

Item	Rental / Purchase Rule
Fracture / traction frames and associated equipment (reported HCPCS)	Neutral: Report devices using the listed HCPCS codes; follow physician order and medical record documentation requirements per policy for rental or purchase determination.
HCPCS codes: E0830, E0870, E0880, E0890, E0900, E0910, E0911, E0912, E0920, E0930, E0940, E0941, E0944, E0945, E0946, E0947	Neutral: Codes are provided for provider reporting. Rental vs. purchase decisions must be supported by the treating physician's order and medical necessity documentation in the member’s record (see policy guidelines).

Definitions

Fracture / traction frames — definition and scope

DefinitionFracture/traction frames and associated equipment are devices usually attached to a hospital bed that use free weights and/or pulleys to pull the injured body part to immobilize and align it, reducing pain, inflammation, and muscle spasms.

Typical componentsIncludes fracture frames, traction frames, and associated equipment such as weights, pulleys, and attachments used to apply traction.

Primary purposeUsed for immobilization and skeletal alignment of an injured extremity or pelvis to reduce pain, inflammation, and muscle spasm.

Place of useTypically attached to a hospital bed; may be used in the home if documentation supports safe application.

Exclusion noteThis policy does not address cervical traction; see Durable Medical Equipment with Attached Table, Policy 1.01.001.

Background

Fracture and traction frames and associated equipment are devices generally attached to a bed that use free weights and/or pulleys to pull an injured body part to immobilize and align skeletal structures. These devices are intended to reduce pain, inflammation, and muscle spasms and are applicable for extremity or pelvic injuries. Use in the home setting is permitted when documentation supports that the device can be safely applied outside the hospital.

Not Covered

Cervical traction devices are not covered under this policy. Coverage and criteria for cervical traction are addressed under Durable Medical Equipment with Attached Table, Policy 1.01.001.