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Vertebral Axial Decompression

» Summary» Procedure Codes
» Description» Selected References
» Prior Approval» Policy History
» Policy
 

Medical Policy: 08.01.18 
Original Effective Date: July 2007 
Reviewed: September 2014 
Revised: January 2008 


Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary based on contract, and individual member benefits must be verified. Wellmark determines medical necessity only if the benefit exists and no contract exclusions are applicable. This medical policy may not apply to FEP. Benefits are determined by the Federal Employee Program.

This Medical Policy document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy will be reviewed regularly and be updated as scientific and medical literature becomes available.


Description: 

Vertebral axial decompression is a type of lumbar traction that has been investigated as a technique to reduce intradiscal pressure and relieve low back pain associated with herniated lumbar discs or degenerative lumbar disc disease.

 

A pelvic harness is worn by the patient. The specially equipped table on which the patient lies is slowly extended, and a distraction force is applied via the pelvic harness until the desired tension is reached, followed by a gradual decrease of the tension. The cyclic nature of the treatment allows the patient to withstand stronger distraction forces compared to static lumbar traction techniques. An individual session typically includes 15 cycles of tension, and 10 to 15 daily treatments may be administered. According to labeled indications from the U.S. Food and Drug Administration (FDA), vertebral axial decompression may be used as a treatment modality for patients with incapacitating low back pain and for decompression of the intervertebral discs and facet joints.

 

Numerous proprietary spinal decompression devices have been granted 510(K) clearance under the FDA's pre-market approval process and are marketed under various trade names. These include the Vax-D, DRX 2000/9000, DRS (Decompression, Reduction, Stabilization) System, Lordex Decompression Unit, CAPP #522, SpineMED, Accu-SPINA, Antalgic-Trak, Extentrac Elite Multi-Directional Disc Decompression (M3D), IDD with Spina System, Triton DTS and other non-surgical spinal decompression devices.


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Prior Approval: 

 

Not applicable


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Policy: 

Vertebral axial decompression for the treatment of low back pain and all other applications is considered investigational.

 

Evidence for the efficacy of vertebral axial decompression is limited. Additional randomized trials with validated outcome measures are required to determine the effectiveness of this treatment for low back pain or other indications





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Procedure Codes and Billing Guidelines: 

  • To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
  • S9090 vertebral axial decompression; should be used to report this service.

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Selected References: 

  • Ramos G, Martin W. Effects of vertebral axial decompression on intradiscal pressure. J Neurosurg 1994;81:350-53.
  • Gose EE, Naguszewski WK, Naguszewski RK. Vertebral axial decompression therapy for pain associated with herniated or degenerated discs or facet syndrome: An outcome study. Neurolog Res;1998 Apr;20 (3):186-90.
  • Sherry E, Kitchener P, Smart R. A prospective randomized controlled study of VAX-D and TENS for the treatment of chronic low back pain. Neurol Res 2001 Oct;23(7):780-4.
  • Deen HG Jr, Rizzo TD, Fenton DS. Sudden progression of lumbar disk protrusion during vertebral axial decompression traction therapy. Mayo Clin Proc. 2003 Dec;78(12):1554-6.
  • Ramos G. Efficacy of vertebral axial decompression on chronic low back pain: study of dosage regimen.Neurol Res. 2004 Apr;26(3):320-4.
  • Apfel CC, Ozlem SC, Martin W, et al. Restoration of disk height through non-surgical spinal decompression is associated with decreased discogenic low back pain: a retrospective cohort study. BMC Musculoskelet Disord. 2010 Jul 8;11:155.

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Policy History: 

Date                                        Reason                               Action

December 2010                      Annual review                     Policy renewed

December 2011                      Annual review                     Policy renewed

December 2012                      Annual review                     Policy renewed

October 2013                         Annual review                     Policy renewed

September 2014                     Annual review                     Policy renewed


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Wellmark medical policies address the complex issue of technology assessment of new and emerging treatments, devices, drugs, etc.   They are developed to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Wellmark medical policies contain only a partial, general description of plan or program benefits and do not constitute a contract. Wellmark does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies may be updated and therefore are subject to change without notice.

*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.

 
Contact Information
New information or technology that would be relevant for Wellmark to consider when this policy is next reviewed may be submitted to:
  Wellmark Blue Cross and Blue Shield
  Medical Policy Analyst
  P.O. Box 9232
  Des Moines, IA 50306-9232
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