MEDICAL POLICY

POLICY
RELATED POLICIES
POLICY GUIDELINES
DESCRIPTION
SCOPE
BENEFIT APPLICATION
RATIONALE
REFERENCES
CODING
APPENDIX
HISTORY

Vertebral Axial Decompression

Number 8.03.09*

Effective Date December 9, 2013

Revision Date(s) 12/09/13; 12/11/12; 11/10/11; 12/14/10; 12/08/09; 10/14/08; 10/09/07; 03/14/06; 05/10/05; 02/10/04; 11/12/02; 09/01/98; 11/11/97

Replaces N/A

*Medicare has a policy.

Policy

Vertebral axial decompression is considered investigational.

Related Policies

7.01.551

Lumbar Spine Decompression Surgery: Discectomy, Foraminotomy, Laminotomy, Laminectomy

8.03.501

Chiropractic Services

Policy Guidelines

The HCPCS code for this therapy is:

S9090 Vertebral axial decompression, per session.

Description

Vertebral 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.

Background

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 to 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.

Regulatory Status

Several devices used for vertebral axial decompression have received 510(K) marketing clearance from the U.S. Food and Drug Administration (FDA). According to labeled indications from the 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.

Scope

Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply.

Benefit Application

N/A

Rationale

This policy has been updated periodically using the MEDLINE® database, with the most recent literature update performed through August 22, 2013. These literature searches have identified a limited number of studies that evaluated patient outcomes associated with vertebral axial decompression. In addition, since a placebo effect may be expected with any treatment that has pain relief as the principal outcome, randomized trials with validated outcome measures are required to determine if there is an independent effect of active treatment.

Literature Review

Randomized Controlled Trials

Results from a randomized sham-controlled trial of intervertebral axial decompression were published in 2009. (1) Sixty subjects with chronic symptomatic lumbar disc degeneration or bulging disc with no radicular pain and no prior surgical treatment (dynamic stabilization, fusion, or disc replacement) were randomly assigned to a graded activity program with an AccuSPINA device (20 traction sessions during 6 weeks, reaching > 50% body weight) or to a graded activity program with a non-therapeutic level of traction (< 10% body weight). In addition to traction, the device provided massage, heat, blue relaxing light, and music during the treatment sessions. Neither patients nor evaluators were informed about the intervention received until after the 14-week follow-up assessment, and intention-to-treat analysis was performed (93% of subjects completed follow-up). Both groups showed improvements in validated outcome measures (visual analog scores for back and leg pain, Oswestry Disability Index, and Short-Form 36), with no differences between the treatment groups. For example, visual analog scores for low back pain decreased from 61 to 32 in the active group and from 53 to 36 in the sham group. Evidence from this recent randomized controlled trial does not support an improvement in health outcomes with vertebral axial decompression.

Sherry and colleagues conducted a randomized trial comparing vertebral axial decompression (using the VAX-D device) with transcutaneous electrical nerve stimulation (TENS). (2) While a 68% success rate was associated with VAX-D compared to a 0% success rate associated with TENS therapy, without a true placebo control, the results are difficult to interpret scientifically. In 2007, 2 small randomized trials (n=27, n=64) found little to no difference between patients treated with or without mechanical traction. (3, 4)

Non-randomized Comparative Studies

In 2004, Ramos reported a nonrandomized comparison of patients receiving 10 sessions versus 20 sessions of vertebral axial decompression treatment. (5) Patients receiving 20 sessions had a response rate of 76% versus a 43% response in those receiving 10 sessions. The study has several limitations and deficiencies; it is not randomized, the follow-up time is not stated, and it does not use a validated outcome measure.

Observational Studies

In 1998, Gose and colleagues reported on an uncontrolled case series of 778 patients. (6) Although this study reported improvements in pain, mobility, and activity in the majority of patients, the study did not detail methods of patient identification or collection of data and did not indicate the duration of treatment success. Finally, the study was uncontrolled.

In a 1994 study of 5 patients, Ramos and Martin reported that intradiscal pressure decreased during the treatment period. (7) Two case series in 2008 reported symptom improvement in patients with chronic low back pain. (8, 9) Due to limitations associated with observational studies of chronic pain, randomized controlled trials are needed to demonstrate efficacy of this treatment.

Summary

Evidence for the efficacy of vertebral axial decompression on health outcomes is limited. Since a placebo effect may be expected with any treatment that has pain relief as the principal outcome, randomized trials with validated outcome measures are required. The only sham-controlled randomized trial published to date did not show a benefit of vertebral axial decompression compared to the control group. Therefore, treatment with vertebral axial decompression is considered investigational.

Medical National Coverage

Medicare has issued a national non-coverage policy for vertebral axial decompression. (10)

References

  1. Schimmel JJ, de Kleuver M, Horsting PP et al. No effect of traction in patients with low back pain: a single centre, single blind, randomized controlled trial of Intervertebral Differential Dynamics Therapy. Eur Spine J 2009; 18(12):1843-50.
  2. Sherry E, Kitchener P, Smart R. 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.
  3. Fritz JM, Lindsay W, Matheson JW et al. Is there a subgroup of patients with low back pain likely to benefit from mechanical traction? Results of a randomized clinical trial and subgrouping analysis. Spine 2007; 32(26):E793-800.
  4. Harte AA, Baxter GD, Gracey JH. The effectiveness of motorised lumbar traction in the management of LBP with lumbo sacral nerve root involvement: a feasibility study. BMC Musculoskelet Disord 2007; 8:118.
  5. Ramos G. Efficacy of vertebral axial decompression on chronic low back pain: study of dosage regimen. Neurol Res 2004;26(3):320-4.
  6. Gose EE, Naguszewski WK, Naguszewski RK. Vertebral axial decompression therapy for pain associated with herniated or degenerated discs or facet syndrome: An outcome study. Neurol Res 1998; 20(3):186-90.
  7. Ramos G, Martin W. Effects of vertebral axial decompression on intradiscal pressure. J Neurosurg 1994; 81(3):350-3.
  8. Beattie PF, Nelson RM, Michener LA et al. 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(2):269-74.
  9. Macario A, Richmond C, Auster M et al. Treatment of 94 outpatients with chronic discogenic low back pain with the DRX9000: a retrospective chart review. Pain Pract 2008; 8(1):11-7.
  10. Centers for Medicare and Medicaid Services. National Coverage Decision for Vertebral Axial Decompression (VAX-D) (160.16). Available online at: http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=160.16&ncd_version=1&basket=ncd%3A160%2E16%3A1%3AVertebral+Axial+Decompression+%28VAX%2DD%2967. Last accessed November 2013.

Coding

Codes

Number

Description

CPT

   

ICD-9 Procedure

   

ICD-9 Diagnosis

   

ICD-10-CM
(effective 10/01/14)

M51.04 - M51.07

Thoracic, thoracolumbar and lumbosacral intervertebral disc disorders with myelopathy code range

 

M51.14 - M51.17

Thoracic, thoracolumbar and lumbosacral intervertebral disc disorders with radiculopathy code range

 

M51.24 - M51.27

Other thoracic, thoracolumbar and lumbosacral intervertebral disc displacement code range

 

M51.34 - M51.37

Other thoracic, thoracolumbar and lumbosacral intervertebral disc degeneration code range

 

M54.5

Low back pain

ICD-10-PCS
(effective 10/01/14)

F07L0YZ

Physical rehabilitation, motor treatment, musculoskeletal system – lower back, range of motion and joint mobility, other equipment

 

F07L6CZ; F07L6HZ, F07L6YZ

Physical rehabilitation, motor treatment, musculoskeletal system – lower back, therapeutic exercise; mechanical, mechanical or electromechanical, and other equipment codes

 

F07L7ZZ

Physical rehabilitation, motor treatment, musculoskeletal system – lower back, manual therapy techniques

HCPCS

S9090

Vertebral axial decompression, per session

Type of Service

Surgery

 

Place of Service

Outpatient

 

Appendix

N/A

History

Date

Reason

11/11/97

Add to Therapy Section - New Policy

09/01/98

Replace policy - Policy updated

11/12/02

Replace policy - Policy reviewed; no change in policy statement

02/10/04

Replace policy - Policy reviewed; no change in policy statement.

05/10/05

Replace policy - Policy reviewed; no change in policy statement.

03/14/06

Replace policy - Policy reviewed with literature search; no change in policy statement. VAX-D added to title.

10/09/07

Replace policy - Policy updated with literature review; no change in policy statement. Reference update and addition.

10/14/08

Replace policy - Policy updated with literature search; no change to the policy statement. References added.

12/08/09

Replace policy - Policy updated with literature search; no change to the policy statement.

12/14/10

Replace policy - Policy updated with literature search; reference 9 added; policy statement unchanged.

11/10/11

Replace policy – Policy updated with literature search through August 2011; policy statement unchanged.

12/19/12

Replace policy. Policy updated with literature search through August 2012; references reordered; policy statement unchanged.

12/09/13

Replace policy. Policy reviewed. Policy Guidelines reformatted for readability. A literature search through August 22, 2013 did not prompt a revision of the references. Policy statement unchanged. CPT code 97012 removed; it is not specific to this policy.

01/21/14

Update Related Policies. Add 7.01.551.


Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA).
┬ę2014 Premera All Rights Reserved.