Mountain State Medical Policy Bulletin
Section: Therapy
Number: Y-19
Topic: Decompression Therapy
Effective Date: February 16, 2009
Issued Date: March 22, 2010
Date Last Reviewed: 03/2010

General Policy Guidelines

Indications and Limitations of Coverage

Decompression therapy, e.g., VAX-D, DRX9000, Spine Med, Tru-Trac Traction Table, is considered experimental/investigational and therefore, not eligible for payment for any condition.  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 decompression therapy in the treatment of back pain.  A participating, preferred, or network provider can bill the member for the denied service.

Description

Decompression therapy is a non-surgical treatment for acute and chronic back pain.  The treatment is performed through the application of 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.  Decompression therapy is primarily 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

This medical policy may not apply to FEP.  Medical policy is not an authorization, certification, explanation of benefits, or a contract.  Benefits are determined by the Federal Employee Program.

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

Long-Term Effect Analysis of IDD Therapy in Low Back Pain: A Retrospective Clinical Pilot Study, American Journal of Pain Management, Vol. 15, No. 3, 07/2005

Systematic Literature Review of Spinal Decompression via Motorized Traction for Chronic Discogenic Low Back Pain, Pain Practice, Vol. 6, Issue 3, 2006

Non-surgical spinal decompression therapy: does the scientific literature support efficacy claims made in the advertising media?, Chiropractic & Osteopathy, Vol. 15, No. 7, 2007

Decompression Therapy for the Treatment of Lumbarsacral Pain, Agency for Healthcare Research and Quality, 04/2007

Treatment of 94 Outpatients with Chronic Discogenic Low Back Pain with the DRX9000: A Retrospective Chart Review, Pain Practice, Vol 8, Issue 1, 2008

Clark J, van Tulder M, Blomberg S. Traction for low-back pain with or without sciatica. Cochrane Database of Systematic Reviews. April 2007.  Accessed at http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003010/frame.html.  Accessed 1/06/10
 
Work Loss Data Institute. Low Back Disorders. Corpus Christi (TX):  Work Loss Data Institute; 2007.  www.guideline.gov.  Accessed 02/09/10

Chou R, Huffman L. Nonpharmacologic Therapies for Acute and Chronic Low Back Pain: A Review of the Evidence for an American Pain Society/American College of Physicians Clinical Practice Guideline. Ann Intern Med. 2007;147(7): 492-504

Work Loss Data Institute. Low back – lumbar & thoracic (acute & chronic). Corpus Christi (TX): Work Loss Data Institute; 2008  www.guideline.gov Accessed 1/07/10

Beattie P, Nelson R, Michener L, Cammarata J, Donley J. Outcomes After a Prone Lumbar Traction Protocol for Patients with Activity-limiting Low Back Pain: A Prospective Case series Study. Arch Phys Med Rehabil. February 2008;89: 269-274

Schwab M. Chiropractic management of a 47-year-old firefighter with lumbar disk extrusion. J Chiropr Med. December 2008; 7(4): 146-54

Last A. Hulbert K. Chronic Low Back Pain: Evaluation and Management. American Family Physician. June 2009;79(12).  www.aafp.org/afp/2009/0615/p1067.html.  Accessed November 20, 2009

Benzon. Raj’s Practical management of Pain. 4th Edition. Mosby;2008. www.mdconsult.com/book.  Accessed November 20, 2009.

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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.