RetiredUnitedHealthcarePolicy CS058LA.N

Home Traction Therapy (for Louisiana Only) – Community Plan Medical Policy

Defines Louisiana Medicaid coverage policy for home traction therapy and related traction/orthotic equipment for UnitedHealthcare Community Plan (Louisiana only) for the policy period May 1, 2025–March 31, 2026. Specifies coverage rationale, equipment approval condition, orthotic device documentation requirements, applicable HCPCS codes, and retirement of the policy effective April 1, 2026.

Policy Summary

PayerUnitedHealthcare

PolicyHome Traction Therapy (for Louisiana Only) – Community Plan Medical Policy

Policy CodePolicy CS058LA.N

Change TypeRetired

Effective DateMay 1, 2025

Next Review Date

Key ActionRequests for approval of orthotic devices must include a complete description of the brace, beneficiary's mental and physical ability to use it, whether the device is a replacement, whether training is indicated, and the plan of training when indicated.

SourceLink

POLICY UPDATE CHANGES

Policy retired; Louisiana plan membership disenrolled on Apr. 1, 2026.

Routine review completed on 05/01/2025 with no change to coverage guidelines.

1State-specific policy (Louisiana only)

8HCPCS codes referenced

2026-04-01Retirement event date (policy retired)

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Defines Louisiana Medicaid coverage policy for home traction therapy and related traction/orthotic equipment for UnitedHealthcare Community Plan (Louisiana only) for the policy period May 1, 2025 – March 31, 2026. Policy status: RETIRED — policy retired and Louisiana plan membership disenrolled on April 1, 2026. Louisiana Medicaid covers home traction therapy (state-specific policy). Note: for informational purposes, the U.S. Food and Drug Administration classifies non-powered orthopedic traction devices as Class I and these devices are exempt from premarket notification.

Policy metadata

Policy numberCS058LA.N

StatusRETIRED

Effective dateMay 1, 2025 - March 31, 2026

Last reviewApril 1, 2026

Retirement event dateApril 1, 2026 (policy retired; Louisiana plan membership disenrolled)

State-specific noteLouisiana only

Medical Necessity / Approval Criteria

Coverage Rationale / Traction Equipment Approval

Covered when ALL of the following are met:

ALL of the following

Beneficiary is covered under Louisiana Medicaid (policy applies only to state of Louisiana)
Traction equipment is being requested for home use
Beneficiary has significant orthopedic impairment which prevents ambulation

Provider Actions / Prior Authorization

Prior Authorization

Prior approval requirement tied to clinical criteria

Traction equipment for home use is approved only when the beneficiary has a significant orthopedic impairment that prevents ambulation. Providers should obtain prior approval consistent with Louisiana Medicaid requirements before supplying home traction equipment.

Documentation Required

Provide orthotic device documentation with request

Approval requests for orthotic devices must include a complete description of the special-type brace, the beneficiary's mental and physical ability to use the device, whether the device is a replacement, whether training is indicated, and the plan of training when training is indicated.

Complete description of the special-type brace
Beneficiary's mental and physical ability to use the device
Whether the device is a replacement
Whether training is indicated
Plan of training when indicated

Referenced Codes

Referenced HCPCS codes (for traction/traction-related 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

Background & Evidence

This policy represents Louisiana Medicaid coverage for home traction therapy and describes FDA classification (informational). The U.S. Food and Drug Administration classifies non-powered orthopedic traction devices as Class I; these devices (including foam or rigid collars and over-the-door pulley, pneumatic, or mechanical systems) are exempt from premarket notification procedures. Providers should also refer to the Louisiana Department of Health Durable Medical Equipment Provider Manual (Chapter Eighteen Section 18.2) for specific state coverage criteria and instructions.

Reference
Louisiana Department of Health Durable Medical Equipment Provider Manual Chapter Eighteen Section 18.2