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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 that 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.  Several devices used for vertebral axial decompression have received 510(k) marketing clearance from the US Food and Drug Administration (FDA).  According to the FDA labeled indications, 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.

Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

8/2001: Reviewed by MPAC, investigational status maintained

2/8/2002: Investigational definition added

5/10/2002: Type of Service and Place of Service deleted

9/26/2002: Internal Disc Decompression (IDD) Therapy^TM added

4/29/2003: Code Reference section updated, "Vertebral axial decompression (VAX-D) may be coded as CPT code 97012 (application of a modality to one or more areas; traction, mechanical)." deleted

3/25/2004: Reviewed by MPAC, remains investigational, Sources updated

5/19/2004: Code Reference section reviewed, no changes

7/11/2008: Policy reviewed, no changes

04/14/2010:  Policy title, description, and statement changed to remove references to Internal Disc Decompression (IDD) Therapy^TM.  FEP verbiage added to the Policy Exceptions section.  Deleted outdated references in the Sources section.  

12/30/2010: Policy reviewed; no changes.

12/01/2011: Policy reviewed. Policy statement unchanged. Deleted outdated references from Sources section.

12/13/2012: Policy reviewed; no changes.

All codes billed for this procedure are considered investigational and not eligible for coverage. 

Non-Covered Codes

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