Medical Policy
Effective Date:04/01/2012 Title:Spinal Decompression Therapy
Revision Date: Document:BI353:00
CPT Code(s):S9090
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

Axial spinal distraction (decompression) is a type of lumbar traction that has been investigated as a non-operative technique to reduce intradiscal pressure and relieve low back pain associated with herniated lumbar discs, degenerative lumbar disc disease, vertebral stenosis, sciatica, or vertebral facet joint pain.  As with many treatments for low back pain, there is no convincing scientific evidence that this technique improves health outcomes.

 
Medical Statement

Spinal decompression therapy for any condition is considered investigational and is not covered.
Limits
Intentially left empty
Reference

Beattie PF, Nelson RM, Michener LA.(2008) Outcomes after a prone lumbar traction protocol for patients with activity-limiting low back pain: a prospective case series study. Arch Phys Med Rehabil, 2008; 89:269-274.

Bigos SJ, Bowyer OR, Braen GR, et al.(1994) Acute Low Back Problems in Adults. AHCPR Pub #95-0642 1994.

Borenstein DG.(1996) Chronic low back pain. Rheum Dis Clin N Am 1996; 22:439-456.

Daniel DM.(2007) Non-surgical spinal decompression therapy: does the scientific literature support efficacy claims made in the advertising media? Chiropractic & Osteopathy, 2007; 15:7-11.

FDA.(1996) 510(k) summary of safety and effectiveness. Center for Devices and Radiological Health. http://www.fda.gov/cdrh/pdf/k951622.pdf. Accessed April 6 1996.

FDA.(1996) FDA enforcement report. http://www.fda.gov/bbs/topics/ENFORCE/ENF00446.html. Accessed April 6 1996.

Gay RE, Bronfort G, Evans RL.(2005) Distraction manipulation of the lumbar spine: a review of the literature. J Manipulative Physiol Ther, 2005; 28:266-273.

Gose EE, Naguszewski WK, Naguszewski RK.(1998) Vertebral axial decompression therapy for pain associated with herniated or degenerated discs or facet syndrome: an outcome study. Neurol Res 1998; 20:186-190.

Harrison DE, Caillet R, et al.(2002) Changes in sagittal lumbar configuration with a new method of extension traction: nonrandomized clinical controlled trial. Arch Phys Med Rehabil 2002; 83:1585-91.

HG Deen, TD Rizzo, DS Fenton.(2003) Sudden progression of lumbar disk protrusion during vertebral axial decompression traction therapy. Mayo Clinic Proc 2003; 78:1554-1556.

http://www.hcfa.gov/pubforms/transmit/transmit.htm. Accessed April 6 1999.

Jensen MC, Brant-Zawadzki MN, Obuchowski N, et al.(1994) Magnetic resonance imaging of the lumbar spine in people without back pain. NEJM 1994; 331:69-73.

Jurecki-Tiller, Bruening W, et al.(2007) Decompressive therapyu for the treatment of lumbosacral pain. AHRQ Technology Assessment Program. http://www.cms.hhs.gov/determinationprocess/downloads/id47TA.pdf.

Macario A, Pergolizzi JV.(2006) Systematic review of spinal decompression via motorized traction for chronic discogenic low back pain. Pain Pract, 2006; 6:171-178.

Macario A, Richmond C, Auster M, et al.(2008) Treatment of 94 outpatients with chronic discogenic low back pain with the DRX9000: a retrospective chart review. Pain Pract, 2008; 8:11-17.

Ramos G, Martin W.(1994) Effects of vertebral axial decompression on intradiscal pressure. J NeuroSurg 1994; 81:350-353.

Ramos G. .(2004) Efficacy of vertebral axial decompression on chronic low back pain: study of dosage regimen. Neurol Res 2004; 26(3):320-4.

Shealy CN, Borgmeyer V.(1997) Decompression, reduction, and stabilization of the lumbar spine: a cost-effective treatment for lumbosacral pain. Am J Pain Management, 1997; 7:63-65.

Sherry E, Kitchener P, Smart R.(2001) A prospective randomized controlled study of VAX-D and TENS for the treatment of chronic low back pain. Neurol Res 2001; 23(7):780-4.

Spinal Decompression Machines. Medical Letter on Drugs and Therapeutics; 2008; 50:41-42.

Tilaro F.(1998) An overview of vertebral axial decompression. Can J Clin Med http://www.vax-d.com/clinical.html. Accessed October 2 1998.

Vertebral axial decompression (VAX-D)—not covered; 35-97. Coverage Issues Manual. http://www.hcfa.gov. Accessed November 1996.

Wheeler AH.(1995) Diagnosis and management of low back pain and sciatica. Am Fam Phys 1995; 52:1333-1341.
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.