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DESCRIPTIONVertebral axial decompression is a type of lumbar traction 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.
Vertebral axial decompression is a type of lumbar traction in which 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 with static lumbar traction techniques. An individual session typically includes 15 cycles of tension, and 10 to 15 daily treatments may be administered. Devices include the VAX-D®, Decompression Reduction Stabilization (DRS®) System, Accu-SPINA® System, DRX-3000®, DRX9000®, SpineMED Decompression Table®, Antalgic-Trak®, Lordex® Traction Unit, and Triton® DTS.
Several devices used for vertebral axial decompression have been cleared for marketing by the U.S. Food and Drug Administration (FDA) throughthe 510(k) process. 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.
POLICYVertebral axial decompression is considered investigational.
POLICY EXCEPTIONSFederal Employee Program (FEP) may dictate that all FDA-approved devices, drugs or biologics may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
POLICY HISTORY6/1997: Approved by Medical Policy Advisory Committee (MPAC)
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) TherapyTM 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) TherapyTM. 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.
01/22/2014: Policy reviewed; no changes.
11/14/2014: Policy reviewed; description updated regarding devices. Policy statement unchanged.
07/23/2015: Code Reference section updated for ICD-10.
05/27/2016: Policy number added. Investigative definition updated in Policy Guidelines.
08/18/2016: Policy description updated. Policy statement unchanged.
SOURCE(S)Blue Cross Blue Shield Association policy # 8.03.09
CODE REFERENCEThis is not an all-inclusive list of non-covered procedure codes.
All codes billed for this procedure are considered investigational and not eligible for coverage.