Medical Policy: 08.01.18
Original Effective Date: July 2007
Reviewed: June 2018
Revised: August 2015
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 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:
In a 2007 clinical practice guideline jointly published by the American College of Physicians and the American Pain Society on the diagnosis and treatment of low back pain, there is little mention of mechanized spinal distraction therapy. What is mentioned on this topic, indicates that there is minimal to no evidence of benefit from traction therapy, regardless of the method used. The panel recommends against the use of traction for all conditions, with the exception of sciatica, for which they make no recommendation for or against the use of this treatment method.
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. The only sham-controlled randomized trial published to date did not show a benefit of vertebral axial decompression compared with the control group.
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.