Medical Policy: 08.01.18 

Original Effective Date: July 2007 

Reviewed: June 2020 

Revised: June 2020 

 

Notice:

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 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:

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.

 

Practice Guidelines and Position Statements

American College of Physicians and American Pain Society

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.

 

Agency for Healthcare Research and Quality (AHRQ)

According to the AHRQ publication on Non-Invasive Techniques for Low Back Pain

  • For low back pain with or without radicular symptoms, a systematic review included 13 trials that found no clear differences with inconsistent effects of traction versus placebo, sham, or no treatment in pain, function, or other outcomes, though two trials reported favorable effects on pain in patients with radicular back pain (SOE: insufficient for pain and function).
  • For low back pain with or without radicular symptoms, a systematic review included five trials that found no clear differences between traction versus physiotherapy versus physiotherapy alone.
  • For low back pain with or without radicular symptoms, a systematic review included 15 trials of traction versus other interventions that found no clear between traction versus other active interventions in pain or function (SOE: low for pain and function). 
  • A systematic review included five trials that found no clear differences between different types of traction. 
  • Eleven trials of traction in a systematic review reported no adverse events or no difference in risk of adverse events versus placebo or other interventions. Three subsequent trials reported findings consistent with the systematic review.

 

Overall, there is insufficient evidence to support the isolated use of mechanical traction as a treatment for chronic LBP.

 

Regulatory Status

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:

  • Acua-Spina System utilizing Intervertebral Differential Dynamics (IDD Therapy)
  • Decompression Reduction Stabilization (DRS) System
  • DRX-3000, DRX-5000
  • DRX9000
  • Lordex Power Traction Unit
  • SpineMED Decompression Table
  • V DRX 9000
  • VAX-D Table
  • Mettler Traction Device [MTD 4000]
  • Dynapro™ DX2, Spinerx LDM
  • Tru Trac 401
  • Integrity Spinal Care System Alpha-SPINA System
  • Spinerx LDM

 

Prior Approval:

Not applicable

 

Policy:

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.

 

Procedure Codes and Billing Guidelines:

To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis codes.

  • S9090 vertebral axial decompression; should be used to report this service.

 

Selected References:

  • 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.
  • Ramos G. Efficacy of vertebral axial decompression on chronic low back pain: study of dosage regimen.Neurol Res. 2004 Apr;26(3):320-4.
  • Martin CW. Vertebral axial decompression for low back pain. Australian Evidence-Based Practice Group, Feb 2005.
  • Jurecki-Tiller M, Bruening W, Tregear S, et al. Decompression therapy for the treatment of lumbosacral pain. Prepared by the ECRI Institute Evidence-Based Practice Center for the Agency for Healthcare Research and Quality (AHRQ) (Contract No. 290-02-0019). Rockville, MD: AHRQ; April 26, 2007.
  • Manchikanti L, Abdi S, Atluri S, et al. An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain Physician. 2013 Apr;16(2 Suppl):S49-283
  • Park WM, Kim K, Kim YH. Biomechanical analysis of two-step traction therapy in the lumbar spine. Man Ther. 2014 May 22.
  • Isgro, M, Buraschi, R, Barbieri, C, Baruzzi, E, Imperio, G, Noro, F, Villafane, JH, and Negrini, S. Conservative management of degenerative disorders of the spine. J Neurosurg Sci. 2014;58(2 Suppl 1):73-76. PubMed 25371952
  • Isner-Horobeti ME, Dufour SP, Schaeffer M, et al. High-force versus low-force lumbar traction in acute lumbar sciatica due to disc herniation: a preliminary randomized trial. J Manipulative Physiol Ther. Nov – Dec 2016;39(9):645-654. PMID 27838140
  • Amir Qaseem, MD, PhD, MHA; Timothy J. Wilt, MD, MPH; Robert M. McLean, MD; Mary Ann Forciea, MD; for the Clinical Guidelines Committee of the American College of Physicians * Clinical Guidelines |4 April 2017 Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians 
  • Chou, R, Qaseem, A, Snow, V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of internal medicine. 2007 Oct 2;147(7):478-91. PMID: 17909209
  • Jurecki-Tiller M, Bruening W, Tregear S, et al. Decompression therapy for the treatment of lumbosacral pain. Prepared by the ECRI Institute Evidence-Based Practice Center for the Agency for Healthcare Research and Quality (AHRQ) (Contract No. 290-02-0019). Rockville, MD: AHRQ

 

Policy History:

  • June 2020 - Annual Review, Policy Revised
  • June 2019 - Annual Review, Policy Renewed
  • June 2018 - Annual Review, Policy Renewed
  • June 2017 - Annual Review, Policy Renewed
  • July 2016 - Annual Review, Policy Renewed
  • August 2015 - Annual Review, Policy Revised
  • September 2014 - Annual Review, Policy Renewed
  • October 2013 - Annual Review, Policy Renewed
  • December 2012 - Annual Review, Policy Renewed
  • December 2011 - Annual Review, Policy Renewed
  • December 2010 - 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.

 

*CPT® is a registered trademark of the American Medical Association.