Medical Policy: 08.01.18
Original Effective Date: July 2007
Reviewed: June 2020
Revised: June 2020
This policy contains information which is clinical in nature. The policy is not medical advice. The information in this policy is used by Wellmark to make determinations whether medical treatment is covered under the terms of a Wellmark member's health benefit plan. Physicians and other health care providers are responsible for medical advice and treatment. If you have specific health care needs, you should consult an appropriate health care professional. If you would like to request an accessible version of this document, please contact customer service at 800-524-9242.
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.
Decompression therapy/mechanical spinal traction for chronic low back pain is described as an alternative, noninvasive, nonsurgical procedure of applying traction to the spine via a computer-driven table which controls the level of disc decompression. It is used in the treatment of low back pain associated with lumbar disc herniation, degenerative disc disease, posterior facet syndrome, sciatica or radiculopathy. The goals are the relief of disabling low back pain and return to normal functioning in patients with lumbar disc disease.
Vertebral axial decompression is a type of lumbar traction/decompression therapy 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 the American College of Physician’s clinical practice guideline (2017) on noninvasive treatments for acute, subacute, and chronic low back pain, evidence was insufficient to determine the effectiveness of traction tables/devices.
According to the AHRQ publication on Non-Invasive Techniques for Low Back Pain
Overall, there is insufficient evidence to support the isolated use of mechanical traction as a treatment for chronic LBP.
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.
Examples of vertebral decompression therapy devices include, but may not be limited to:
Decompression therapy, including vertebral axial decompression, for the treatment of low back pain and all other applications is considered investigational.
Evidence for the efficacy of decompression therapy/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. A placebo effect may be expected with any treatment that has pain relief as the principal outcome, RCTs with sham controls and validated outcome measures are required. Specifically, the few studies showing a semblance of efficacy have not demonstrated that vertebral axial decompression therapy is superior to, or even comparable with, existing treatments.
To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis codes.
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.
*CPT® is a registered trademark of the American Medical Association.