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Date Printed: August 23, 2017: 01:21 PM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

01-97000-07

Original Effective Date: 10/15/07

Reviewed: 08/25/11

Revised: 05/11/14

Subject: Vertebral Axial Decompression

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
Other References Update  

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.

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. 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.

POSITION STATEMENT:

Vertebral Axial Decompression (e.g. VAX-D) and Decompression reduction stabilization (DRS)® System are considered experimental or investigational, as there is insufficient clinical evidence to support the effects on health outcomes.

BILLING/CODING INFORMATION:

The following codes may be used to describe:

CPT Coding:

There are no specific CPT codes describing vertebral axial decompression.

HCPCS Coding:

S9090

Vertebral Axial Decompression, per session (investigational)

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following National Coverage Determination (NCD) was reviewed on the last guideline reviewed date: Vertebral Axial Decompression (VAX-D) (160.16) located at cms.gov.

The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Noncovered Services (L29288) located at fcso.com.

DEFINITIONS:

Intradiscal: within the disc.

Intervertebral discs: a disc interposed between the bodies of adjacent vertebrae. It is composed of an outer fibrous part that surrounds the central nucleus pulposus.

Nucleus pulposus: a central gelatinous mass within the disc.

RELATED GUIDELINES:

Physical Therapy (Physical Medicine), 01-97000-01

OTHER:

Indexing terms:

Note: The use of specific product names is illustrative only. It is not intended to be a recommendation of
one product over another, and is not intended to represent a complete listing of all products available.

Accu-Spina System™
Alpha-Spina System
Antalgic-Trak
Decompression Reduction Stabilization DRS System
DRX9000™
Intervertebral Differential Dynamics (IDD) Therapy
Lordex Lumbar Spine System
VAX-D®

REFERENCES:

  1. Agency for Healthcare Research and Quality (AHRQ); Technology Assessment Program; Decompression Therapy for the Treatment of Lumbosacral Pain (04/26/07).
  2. AHRQ/National Guideline Clearinghouse. NCG-6562. Low back – lumbar & thoracic (acute & chronic). Revised June 10, 2008. (Accessed 09/07/10).
  3. AHRQ/National Guideline Clearinghouse. NCG-8517. Low back – lumbar & thoracic (acute & chronic). Revised 06/09/11. (Accessed 07/21/11).
  4. American Medical Association CPT Coding (current edition).
  5. Axiom Worldwide website. The DRX9000™ website. Accessed 08/14/07.
  6. Blue Cross Blue Shield Association Medical Policy Reference Manual. Medical Policy 8.03.09 - Vertebral Axial Decompression (07/10/08).
  7. Centers for Medicare and Medicaid Services (CMS) Local Coverage Determination (LCD) List of Medicare Non-covered Services, (L5780). (Revised 06/30/08).
  8. Centers for Medicare and Medicaid Services (CMS) Local Coverage Determination (LCD) Non-covered Services, (L29288). Revised 07/01/11. (Accessed07/21/11).
  9. Centers for Medicare and Medicaid Services (CMS) National Coverage Determination (NCD) for Vertebral Axial Decompression (VAX-D), Pub. 100-3, Section 160.16 04/15/97. (Accessed07/21/11).
  10. Daniel DM. Parker Research Institute, Parker College of Chiropractic, Dallas, Texas, USA. Non-surgical spinal decompression therapy: does the scientific literature support efficacy claims made in the advertising media? Chiropr Osteopat. 2007 May 18; 15:7.
  11. ECRI Target Database Report; Decompression Therapy for Chronic Low-back Pain, (10/02; updated 09/01/05).
  12. HAYES Medical Technology Directory; Mechanized Spinal Distraction Therapy for Low Back Pain, (01/13/03; updated 01/03/08).
  13. Ingenix HCPCS Level II Coding (current edition).
  14. John Wiley & Sons, LTD. Vertebral axial decompression for low back pain. Cochrane Library, Health Technology Assessment Database 2007 Issue 3. HTA-20060876.
  15. John Wiley & Sons, LTD. Vertebral axial decompression therapy for low back pain. Cochrane Library, Health Technology Assessment Database 2007 Issue 3. HTA-20020073.
  16. 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 Oct; 23(7): 780-4.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 08/25/11.

GUIDELINE UPDATE INFORMATION:

10/15/07

New Medical Coverage Guideline.

10/15/08

Scheduled review; no change in position statement. Update references.

10/15/09

Scheduled review; no change in position statement. Update description section.

10/15/10

Scheduled review; no change in position statement; references updated.

09/15/11

Scheduled review; no change in position statement; revised description section and updated references.

02/15/12

Revision; deleted CPT code 97012.

05/11/14

Revision: Program Exceptions section updated.

Date Printed: August 23, 2017: 01:21 PM