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