RetiredUnitedHealthcarePolicy CS058LA.N

Home Traction Therapy (for Louisiana Only) Retired April 1, 2026

Louisiana Medicaid coverage policy for home traction therapy and related traction/orthotic devices for beneficiaries in Louisiana; governs UnitedHealthcare Community Plan Louisiana members during the policy effective period.

Policy Summary

PayerUnitedHealthcare

PolicyHome Traction Therapy (for Louisiana Only) Retired April 1, 2026

Policy CodePolicy CS058LA.N

Change TypeRetired

Effective DateMay 1, 2025 - March 31, 2026

Next Review DateN/A

Key ActionInclude full device description and beneficiary ability to use when requesting orthotic device approval.

SourceLink

POLICY UPDATE CHANGES

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

Routine review on May 1, 2025 with no change to coverage guidelines.

Louisiana-onlystate-specific applicability

Retired 2026-04-01policy retirement date

Coveredcoverage stance for home traction therapy (when criteria met)

E0830..E0941listed HCPCS traction codes referenced

Coverage / Medical Necessity Criteria

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inv-01: Medical Necessity Criteria — Covered when ALL of the following are met:

Covered when ALL of the following are met:

Coverage for Home Traction Therapy: Louisiana Medicaid covers home traction therapy.

Per state coverage rationale.

Significant Orthopedic Impairment: Beneficiary has significant orthopedic impairment which prevents ambulation.

Traction equipment is approved only under this condition.

Orthotic Device Documentation: Requests for orthotic devices (including cervical traction collars) 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 indicated.

Required documentation for orthotic device approval.

Codes in the HCPCS list that are marked with an asterisk (*) indicate they are not on the State of Louisiana Medicaid Fee Schedule and therefore may not be covered by the State of Louisiana Medicaid Program. Inclusion of a code in this policy is for reference only and does not guarantee coverage or payment; benefit coverage is determined by federal, state, or contractual requirements.

HCPCS / Coding References

Referenced HCPCS CodesHCPCS

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 & Authorization Requirements

Billing Rule

HCPCS Codes (reference only)

HCPCS codes referenced — Inclusion does not guarantee coverage; benefit coverage determined by contract/fee schedule.

Listing of a code in this policy does not imply coverage or right to reimbursement; verify benefits/fee schedule.
Codes marked with * may not be on the Louisiana Medicaid Fee Schedule and therefore may not be covered.

Prior Authorization

Provider Actions

Provider Actions — Prior authorization and documentation are required for orthotic devices and traction equipment requests. Requests should be submitted to the plan per standard prior authorization processes.

Prior authorization required when indicated by contract/medical policy.
Verify member eligibility and benefit limitations before ordering.
Submit prior authorization requests with the required supporting documentation listed below.

Documentation Required

Required Documentation for Orthotic Devices

Required documentation for orthotic devices — The request for approval should include all of the following to support medical necessity and safe use.

A complete description of the specific type of brace or orthotic device requested (model, make, and function).
The beneficiary's mental and physical ability to use the device (including ability to don/doff and comply with use).
Whether the device is a replacement for an existing device (include date of prior device and reason for replacement).
Whether training is indicated, and if so, the plan of training (who will provide training, frequency, and goals).
Clinical records demonstrating the diagnosis, functional impairment, and objective findings supporting the need for the orthotic device.

Denial Risk

Traction Equipment Approval Condition

Traction equipment approval condition — Traction equipment is approved only if the beneficiary has a significant orthopedic impairment that prevents ambulation. Cervical traction collars are considered under Orthotic Devices.

Approval is contingent on documentation showing the beneficiary is non-ambulatory due to orthopedic impairment.
Cervical traction devices are reviewed in the context of orthotic device criteria and required documentation.

DME Medical Necessity Rules

inv-11: DME Medical Necessity Criteria — Coverage limited to beneficiaries meeting the following:

Coverage limited to beneficiaries meeting the following:

Significant impairment preventing ambulation: Beneficiary has significant orthopedic impairment which prevents ambulation.

Required for traction equipment approval.

Proper documentation for orthotic devices: Provide device description, beneficiary mental and physical ability to use the device, whether device is a replacement, whether training is indicated, and the plan of training when indicated.

Must be included with request for approval.

Rental and Purchase Guidelines

Equipment	Rental vs Purchase	Notes / State fee-schedule status
Ambulatory traction device (E0830)	Unspecified in policy	Listed for reference; code marked with * in policy indicates it may not be on the State of Louisiana Medicaid Fee Schedule
Traction frame, headboard-attached, cervical (E0840)	Unspecified in policy	Listed for reference; inclusion does not guarantee coverage — benefit determined by federal, state, or contractual requirements
Traction equipment, cervical, free‑standing stand/frame, pneumatic (E0849)	Unspecified in policy	Listed for reference; inclusion does not guarantee coverage
Traction stand, freestanding, cervical traction (E0850)	Unspecified in policy	Listed for reference; inclusion does not guarantee coverage
Cervical traction equipment not requiring additional stand or frame (E0855)	Unspecified in policy	Listed for reference; inclusion does not guarantee coverage
Cervical traction device with inflatable air bladder(s) (E0856)	Unspecified in policy	Marked with * in policy — may not be on the State of Louisiana Medicaid Fee Schedule and therefore may not be covered
Traction equipment, overdoor, cervical (E0860)	Unspecified in policy	Listed for reference; inclusion does not guarantee coverage
Gravity assisted traction device, any type (E0941)	Unspecified in policy	Listed for reference; inclusion does not guarantee coverage

Definitions

inv-09: Traction equipment — definition and approval limitation

DefinitionTraction equipment: devices used to apply traction for orthopedic purposes; cervical traction collars are considered under Orthotic Devices.

Approval limitationApproved only if the beneficiary has significant orthopedic impairment which prevents ambulation.

Place of usePolicy applies to home use under Louisiana Medicaid when criteria are met.

inv-10: Orthotic devices — definition listing braces, supports, repairs, etc.

DefinitionOrthotic devices: leg braces, neck braces, knee braces and supports, spinal supports, splints, brace attachments, and repairs.

Includes cervical traction collarsCervical traction collars are considered under Orthotic Devices.

Required documentation for approvalRequest must include: complete description of special type brace; 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 indicated.

Replacement & Orthotic Device Rules

inv-13: Orthotic devices — replacement considerations

Replacement status requirementIf the device is a replacement, the request for approval must state that the device is a replacement.

Replacement intervalNo specific replacement interval is specified in this policy; replacement requests must still indicate replacement status.

Documentation to accompany replacement requestsProvide beneficiary's mental and physical ability to use the device and whether training is indicated plus the training plan when applicable.

Documentation Requirements

Documentation Required

Documents required with request for approval

Include the following items with any request for orthotic/traction device approval: a complete device description, beneficiary mental and physical ability to use it, whether it is a replacement, and whether training is indicated with the training plan when applicable.

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

Background

Traction devices include a range of non‑powered and powered systems used to apply orthopedic traction in the home setting. Common device types referenced in this policy are ambulatory traction devices, traction frames/stands (headboard‑attached or freestanding), overdoor traction equipment, cervical traction equipment (including inflatable air bladder devices), and gravity‑assisted traction devices.

This Louisiana Medicaid policy lists HCPCS codes for traction and related devices for reference; however, listing a code does not imply it is covered. Codes labeled with an asterisk (*) are specifically identified by the Louisiana Department of Health as not appearing on the State Fee Schedule and therefore may not be covered by the State program. Providers should follow the policy’s coverage criteria and state fee schedule guidance when requesting authorization or submitting claims.

Policy Summary

PayerUnitedHealthcare

PolicyHome Traction Therapy (for Louisiana Only) Retired April 1, 2026

Policy CodePolicy CS058LA.N

Change TypeRetired

Effective DateMay 1, 2025 - March 31, 2026

Next Review DateN/A

Key ActionInclude full device description and beneficiary ability to use when requesting orthotic device approval.

SourceLink

On This Page

OpenPayer

Home Traction Therapy (for Louisiana Only) Retired April 1, 2026

Coverage / Medical Necessity Criteria

HCPCS / Coding References

Provider Actions & Authorization Requirements

DME Medical Necessity Rules

Rental and Purchase Guidelines

Definitions

Replacement & Orthotic Device Rules

Documentation Requirements

Background

Not Covered / Limitations