Mountain State Medical Policy Bulletin
Section: Therapy
Number: Y-19
Topic: Vertebral Axial Decompression (VAX-D)
Effective Date: August 1, 2005
Issued Date: August 1, 2005
Date Last Reviewed: 06/2005

General Policy Guidelines

Indications and Limitations of Coverage

Vertebral axial decompression (VAX-D) is considered experimental/investigational and therefore, not eligible for payment.  There is insufficient evidence in medical literature to support the effectiveness of this procedure.  The data are insufficient to permit scientific conclusions regarding the role of vertebral axial decompression in the treatment of low back pain associated with herniated lumbar discs or degenerative lumbar disc disease.  A participating, preferred, or network provider can bill the member for the denied service.

Description

Vertebral axial decompression is a non-surgical treatment for chronic low back pain.  The treatment is performed through the application of pelvic traction.  Traction is provided through the use of a split table specifically designed to slowly separate, thereby applying a distraction force to the lumbar spine.  While the patient lies prone on the table, the distraction force is applied in cycles of traction (decompression) and relaxation.  The intensity of the decompression cycle can be adjusted to the patient's level of tolerance or comfort.  Vertebral axial decompression is performed to treat low back pain caused by herniated discs and degenerative disc disease.

 


NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes

S9090     

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Under the Federal Employee Program, all services that utilize FDA-approved drugs, devices, or biological products are eligible when intended for the treatment of a serious or life-threatening condition and when medically necessary and appropriate for the patient's condition. Vertebral axial decompression and intradiscal distraction therapy are considered eligible services when determined medically necessary based on the patient's condition.

Also refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

National Blue Cross Blue Shield Association Medical Policy 8.03.09, Vertebral Axial Decompression, 03/2003

CMS On-line Manual Pub. 100-03, Chapter 1, Section 160.16

Efficacy of Vertebral Axial Decompression on Chronic Low Back Pain: Study of Dosage Regimen, Neurological Research, Vol. 26, 04/2004

Sudden Progression of Lumbar Disk Protrusion During Vertebral Axial Decompression Traction Therapy, Mayo Clin Proc, Vol. 78, 12/2003

Vertebral Axial Decompression Therapy for Pain Associated with Herniated or Degenerated Discs or Facet Syndrome: An Outcome Study, Neurological Research, Vol. 20, 04/1998

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Glossary




This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.