Cervical Traction Device Criteria

Traction is a technique in which opposite forces are applied to separate parts of the body to stretch soft tissues, and /or separate bony structures.  Intermittent cervical traction is an acceptable treatment for a number of musculoskeletal disorders of the neck.  Cervical traction focuses on releasing tension and pressure on neck structures.  It may be used after initial modalities have been tried at home or in conjunction with comprehensive medical and physical therapy.

Medically Necessary:

1. 1. An “over the door” home cervical traction device is considered medically necessary provided the criteria below are met:
      • The patient has a musculoskeletal or neurologic impairment requiring traction equipment.
      • The appropriate use of a home cervical traction device has been demonstrated to the patient and he/she is able to tolerate the selected device.  
   2. Pneumatic cervical traction devices applying traction force to the head and neck, other than the mandible, and cervical traction equipment not requiring an additional stand or frame are medically necessary when all of the following criteria are met:
      • The patient has a musculoskeletal or neurologic impairment requiring traction equipment.
      • The appropriate use of a home cervical traction device has been demonstrated to the patient and he/she is able to tolerate the selected device.  
      • The treating physician orders and documents the medical necessity of 12 pounds or more of home cervical traction; or
      • The member has distortion of the lower jaw or neck anatomy (i.e. radical neck dissection such that a chin halter is unable to be utilized), or has another limitation making it unsafe to use “over the door” cervical traction (i.e. rotator cuff injury).

Not Medically Necessary:

• Non-pneumatic cervical traction applied by attachment to a free-standing frame or stand, or cervical traction applied by attachment to a headboard is considered experimental.
• Cervical collars with inflatable air bladders which can be used with ambulation are not reasonable and medically necessary.

Initiated: May 2016

Reviewed: 1/17, 1/18, 1/19, 2/20, 9/24

Revised: 5/21, 9/22, 9/23