CurrentUnitedHealthcarePolicy CS058ID.B

Home Traction Therapy (for Idaho Only)

State-specific UnitedHealthcare medical policy for home traction therapy (Idaho only) describing coverage criteria for cervical traction devices (referencing DME MAC LCD L33823) and declaring all other home traction devices unproven and not medically necessary for low back disorders with or without radiculopathy.

Policy Summary

PayerUnitedHealthcare

PolicyHome Traction Therapy (for Idaho Only)

Policy CodePolicy CS058ID.B

Change TypeRevised (delegated cervical criteria; narrowed exclusion)

Effective DateAug 1, 2025

Next Review Date

Key ActionFor home cervical traction devices, providers must follow the medical necessity clinical coverage criteria in the DME MAC LCD for Cervical Traction Devices (L33823) when requesting coverage or prior authorization.

SourceLink

POLICY UPDATE CHANGES

Added instruction to refer to the DME MAC LCD Cervical Traction Devices (L33823) for medical necessity clinical coverage criteria for home traction therapy using cervical traction devices.

Replaced language that previously stated 'home traction therapy is unproven and not medically necessary for treating low back and neck disorders with or without radiculopathy' with language specifying that only traction devices not referenced in the Medicare LCD are unproven and not medically necessary for low back disorders with or without radiculopathy.

Updated Description of Services, Clinical Evidence, and References sections to reflect current information.

1State covered (Idaho)

8HCPCS codes listed

Coverage Summary

This policy addresses UnitedHealthcare coverage of home traction therapy in the state of Idaho only, including Idaho Medicaid Plus plans. (Policy Number CS058ID.B, Effective Date: August 1, 2025; Last review: August 1, 2025.)

State-specific criteria delegate medical necessity clinical coverage criteria for home cervical traction devices to the DME MAC Local Coverage Determination for Cervical Traction Devices (L33823), while coverage for other traction devices is addressed separately.

The policy focuses on declaring home traction devices that are not referenced in the Medicare LCD L33823 as unproven and not medically necessary for treating low back disorders (with or without radiculopathy), based on insufficient evidence of efficacy.

Key Policy Facts

Policy NumberCS058ID.B

SubjectHome Traction Therapy (Idaho)

ScopeState-specific UnitedHealthcare medical policy for home traction therapy (Idaho only) describing coverage criteria for cervical traction devices (referencing DME MAC LCD L33823) and declaring all other home traction devices unproven and not medically necessary for low back disorders with or without radiculopathy.

State coveredIdaho (including Idaho Medicaid Plus)

HCPCS codes listedE0830, E0840, E0849, E0850, E0855, E0856, E0860, E0941

Medicare LCD referencedCervical Traction Devices (L33823)

StatusCURRENT

Effective Date / Last ReviewEffective: August 1, 2025; Last Review: August 1, 2025

Medical Necessity Criteria

State-Specific Criteria (Cervical Traction Devices)

Coverage determination for home cervical traction devices:

State-specific delegation: Medical necessity clinical coverage criteria for home traction therapy using cervical traction devices are determined by referring to the DME MAC LCD for Cervical Traction Devices (L33823).

Policy delegates specific clinical criteria to LCD L33823.

State limitation: This policy applies only to the state of Idaho, including Idaho Medicaid Plus plans.

State limitation

Non State-Specific Criteria (All Other Traction Devices)

Coverage statement for non-cervical or traction devices not referenced in the Medicare LCD:

Not Medically Necessary / Unproven

The prior blanket exclusion that labeled home traction therapy as unproven and not medically necessary for treating both low back and neck disorders has been narrowed. The revised policy now specifies that only traction devices not referenced in the Medicare LCD L33823 are considered unproven and not medically necessary for low back disorders (with or without radiculopathy).

For home cervical traction devices, providers must follow the medical necessity clinical coverage criteria in the DME MAC LCD for Cervical Traction Devices (L33823); the exclusion applies to "all other" traction devices that are not referenced in that Medicare LCD.

Multiple high-quality evidence sources conclude that mechanical traction lacks sufficient evidence of benefit for low back pain. A 2013 Cochrane update (Wegner et al.; building on Clarke et al., 2007) found low- to moderate-quality evidence that traction may make little or no difference in pain, function, global improvement, or return to work compared with placebo, sham, or no treatment, and noted limited-quality studies with small samples and risk of bias.

The NICE guideline NG59 (2016) specifically recommends not to offer traction for managing low back pain with or without sciatica.

The VA/DoD 2022 guideline and the American College of Physicians (2017) similarly state there is insufficient evidence to recommend for or against mechanical lumbar traction and that traction has not been proven effective for chronic low back pain.

Coding

Referenced HCPCS Codes (traction devices)HCPCS

E0830	Ambulatory traction device, all types, each.
E0840	Traction frame, attached to headboard, cervical traction.
E0849	Traction equipment, cervical, free-standing stand/frame, pneumatic, applying traction force to other than mandible.
E0850	Traction stand, freestanding, cervical traction.
E0855	Cervical traction equipment not requiring additional stand or frame.
E0856	Cervical traction device, with inflatable air bladder(s).
E0860	Traction equipment, overdoor, cervical.
E0941	Gravity assisted traction device, any type.

Provider Actions

Documentation Required

Follow DME MAC LCD L33823 for Cervical Traction

For home cervical traction devices, providers must follow the medical necessity clinical coverage criteria in the DME MAC LCD for Cervical Traction Devices (L33823) when requesting coverage or prior authorization.

Applies to prior authorization and coverage requests for home cervical traction devices; follow LCD L33823 for medical necessity criteria.

Denial Risk

Non-covered: Home Traction for Low Back Disorders

Claims for home traction devices not referenced in LCD L33823 for treatment of low back disorders with or without radiculopathy are considered unproven and not medically necessary and are at risk of denial.

Claims for devices not referenced in Medicare LCD L33823 (i.e., all other traction devices) are at risk of denial as unproven and not medically necessary.

Background & Evidence

Traction involves applying forces to the spine to stretch or separate structures, with the objective of relieving pain, relaxing muscle spasm, and decompressing spinal structures. The type and application of traction depend on the individual’s age, weight, and medical condition.

Lumbar traction has been used short term in various settings, including outpatient and home settings, and can be applied intermittently or continuously during a treatment session.

However, for low back disorders (with or without radiculopathy), the published peer-reviewed scientific literature shows insufficient, conflicting, or poor-quality evidence to demonstrate net benefit of home traction, and additional research is recommended.

Source	Summary
Cochrane (Wegner et al., 2013 / Clarke et al., 2007)	Low- to moderate-quality evidence shows traction may make little or no difference in pain/function for low back pain; overall evidence limited and not clinically relevant.
NICE NG59 (2016)	Recommendation not to offer traction for managing low back pain with or without sciatica.
VA/DoD (2022) and ACP (2017)	Insufficient evidence to recommend for or against mechanical lumbar traction; not proven effective for chronic low back pain.

Home traction therapy: Use of cervical or lumbar traction devices in a home setting intended to relieve spinal pain or decompress spinal structures.

DME MAC LCD L33823: Local Coverage Determination for Cervical Traction Devices issued by the DME MAC; this LCD is referenced for clinical criteria for home cervical traction devices.

Medicare Determinations

Name	Number	Type	Effective Date
Cervical Traction Devices	L33823	LCD

Revision History

08/01/2025revisedLatest

ADDED: Refer to DME MAC LCD Cervical Traction Devices (L33823) for medical necessity clinical coverage criteria for home cervical traction devices. (Material change)

08/01/2025revisedLatest

REPLACED: Prior blanket exclusion language with a narrower exclusion — home traction therapy is now considered unproven and not medically necessary only for traction devices not referenced in the Medicare LCD (i.e., excludes only devices not covered by LCD L33823). (Material change)

08/01/2025