Vertebral Axial Decompression (VAD-X)

Description of Procedure or Service

Vertebral axial decompression (also referred to as mechanized spinal distraction therapy) is used as traction therapy to treat chronic low back pain. Specific devices available are described in the Regulatory Status section. In general, during treatment, the patient wears a pelvic harness and lies prone on a specially equipped table. The table 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.

Regulatory Status

Several devices used for vertebral axial decompression have been cleared for marketing by the U.S. Food and Drug Administration (FDA) through the 510(k) process. Examples of these 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. According to labeled indications from 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.

***Note: This Medical Policy is complex and technical. For questions concerning the technical language and/or specific clinical indications for its use, please consult your physician.

Policy

Vertebral Axial Decompression is considered investigational. BCBSNC does not cover investigational services or procedures.

Benefits Application

This medical policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this medical policy.

When Vertebral Axial Decompression is covered

Not applicable

When Vertebral Axial Decompression is not covered

Vertebral Axial Decompression is considered investigational. BCBSNC does not cover investigational services.

Policy Guidelines

For individuals who have chronic lumbar pain who receive vertebral axial decompression, the evidence includes randomized controlled trials (RCTs). Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. Evidence for the efficacy of vertebral axial decompression on health outcomes is limited. Because a placebo effect may be expected with any treatment that has pain relief as the principal outcome, RCTs with sham controls and validated outcome measures are required. The only sham-controlled randomized trial published to date did not show a benefit of vertebral axial decompression compared with the control group. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Billing/Coding/Physician Documentation Information

This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.

Applicable codes: S9090

Scientific Background and Reference Sources

BCBSA Medical Policy Reference Manual - 5/97

Specialty Matched Consultant Advisory Panel - 11/1999

Medical Policy Advisory Group - 12/2/1999

Specialty Matched Consultant Advisory Panel - 5/2001

BCBSA Medical Policy Reference Manual - 7/12/2002; 8.03.09

Specialty Matched Consultant Advisory Panel - 5/2003

ECRI Target Report #832 (2002, October). Decompression therapy for chronic low back pain.

BCBSA Medical Policy Reference Manual [Electronic Version]. 8.03.09, 10/9/03.

ECRI Custom Hotline Response (2005, September). Decompression therapy for chronic low back pain.

Centers for Medicare and Medicaid Services. National Coverage Determination 160.16.

Washington State Department of Labor and Industries. Health Technology Assessment Update for Powered Traction Devices for Intervertebral Decompression (June 14, 2004). 

Washington State Department of Labor and Industries. Health Technology Assessment Update for Vertebral Axial Decompression (Vax-D) (1999). 

Medicare Services Advisory Committee (MSAC). Assessment report for Vertebral axial decompression (VAX-D). MSAC Application number 1012. Canberra, Australia: MSAC; June 2001. 

BCBSA Medical Policy Reference Manual [Electronic Version]. 8.03.09, 3/7/06

VAX-D Medical Technologies LLC. 310 Mears Blvd, Oldsmar, FL, 24677. 

Wang G. Powered traction devices for intervertebral decompression. Health Technology Assessment Update. Olympia, WA: Washington State Department of Labor and Industries, Office of the Medical Director; June 14, 2004. 

Workers Compensation Board, (WCB) Evidence Based Practice Group. Vertebral axial decompression for low back pain. February 2005.

Jurecki-Tiller M, Bruening W, Tregear S, et al. Decompression therapy for the treatment of lumbosacral pain. Prepared by the ECRI Institute Evidence-Based Practice Center for the Agency for Healthcare Research and Quality (AHRQ) (Contract No. 290-02-0019). Rockville, MD: AHRQ; April 26, 2007. 

BCBSA Medical Policy Reference Manual [Electronic Version]. 8.03.09, 7/10/08

BCBSA Medical Policy Reference Manual [Electronic Version]. 8.03.09, 10/6/09

Specialty Matched Consultant Advisory Panel review 7/2010

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. 

BCBSA Medical Policy Reference Manual [Electronic Version]. 8.03.09, 10/8/10

BCBSA Medical Policy Reference Manual [Electronic Version]. 8.03.09, 10/4/11 

Specialty Matched Consultant Advisory Panel review 7/2012

BCBSA Medical Policy Reference Manual [Electronic Version]. 8.03.09, 10/11/12

Workers Compensation Board, (WCB) Evidence Based Practice Group. Vertebral axial decompression for low back pain. July 2012. 

Specialty Matched Consultant Advisory Panel review 7/2013

Medical Director review 7/2013

BCBSA Medical Policy Reference Manual [Electronic Version]. 8.03.09, 10/10/13

Specialty Matched Consultant Advisory Panel review 7/2014

Medical Director review 7/2014

BCBSA Medical Policy Reference Manual [Electronic Version]. 8.03.09, 10/09/14

Specialty Matched Consultant Advisory Panel review 6/2015

Specialty Matched Consultant Advisory Panel 6/2016

BCBSA Medical Policy Reference Manual [Electronic Version]. 8.03.09, 06/16/2016

BCBSA Medical Policy Reference Manual [Electronic Version]. 8.03.09, 4/13/2017

Specialty Matched Consultant Advisory Panel 6/2017

BCBSA Medical Policy Reference Manual [Electronic Version]. 8.03.09, 4/12/2018

Specialty Matched Consultant Advisory Panel 6/2018

BCBSA Medical Policy Reference Manual [Electronic Version]. 8.03.09, 4/8/2019

Specialty Matched Consultant Advisory Panel 7/2019

BCBSA Medical Policy Reference Manual [Electronic Version]. 8.03.09, 4/16/2020

Specialty Matched Consultant Advisory Panel 6/2020

BCBSA Medical Policy Reference Manual [Electronic Version]. 8.03.09, 4/8/2021

Specialty Matched Consultant Advisory Panel 6/2021

Vanti C, Turone L, Panizzolo A, et al. Vertical traction for lumbar radiculopathy: a systematic review. Arch Physiother. Mar 15 2021;11(1): 7

Specialty Matched Consultant Advisory Panel 6/2022

Specialty Matched Consultant Advisory Panel 6/2023

Medical Director Review 6/2023

Specialty Matched Consultant Advisory Panel 6/2024

Medical Director Review 6/2024

Policy Implementation/Update Information

4/99 Original policy issued

7/99 Reformatted, Medical Term Definitions added.

12/99 Reaffirmed, Medical Policy Advisory Group

5/01 System change. Revised. Added statement under Benefits Application to refer to the policy for Urinary Incontinence, Treatment. Specialty Matched Consultant Advisory Panel. No changes to policy. Coding format change.

5/03 Specialty Matched Consultant Advisory Panel review. No criteria changes.

6/2/2005 Specialty Matched Consultant Advisory Panel Review on 5/23/2005. No changes made to the policy statement. OTH 8160 added as key word. Benefits application and Billing/Coding sections updated for consistent policy language. References added.

11/3/05 Revised description of procedure. Removed FDA statement from Policy Guidelines and added rationale. Added "DRX9000, DRS System and mechanical traction" to Policy Key Words. Added Medical Term Definitions. Updated Reference Source. No changes to policy criteria.

6/18/07 Routine biennial review. Updated references. Specialty Matched Consultant Advisory Panel Review on 5/18/07. No changes to policy coverage criteria. (adn)

7/6/09 References updated. Specialty Matched Consultant Advisory Panel Review meeting 5/21/09. No change to policy statement. (adn)

8/17/10 Specialty Matched Consultant Advisory Panel review 7/2010. Removed Medical Policy number. References updated. (mco)

8/16/11 Specialty Matched Consultant Advisory Panel review 7/2011. References updated. Policy Guidelines updated. No changes to policy statement. (mco)

12/6/11 References updated. No changes to Policy Statement. (mco)

8/7/12 Specialty Matched Consultant Advisory Panel review 7/2012. No changes to Policy Statement. (mco)

12/11/12 References updated. No changes to Policy Statement. (mco)

7/30/13 Specialty Matched Consultant Advisory Panel review 7/2013. References updated. Medical Director review 7/013. No changes to Policy Statements. (mco)

11/26/13 References updated. No changes to Policy Statements. (mco)

8/12/14 Specialty Matched Consultant Advisory Panel review 7/2014. Medical Director review 7/2014. No changes to Policy Statements. (mco)

12/30/14 Reference added. No change to Policy statement. (sk)

7/28/15 Specialty Matched Consultant Advisory Panel review 6/24/2015. (sk)

7/26/16 Specialty Matched Consultant Advisory Panel review 6/29/2016. Reference added. (sk)

5/26/17 Reference added. Description section updated. (sk)

7/28/17 Specialty Matched Consultant Advisory Panel review 6/28/2017. (sk)

7/13/18 Reference added. Specialty Matched Consultant Advisory Panel review 6/27/2018. (sk)

9/10/19 Reference added. Specialty Matched Consultant Advisory Panel review 7/30/2019. (sk)

6/30/20 Reference added. Specialty Matched Consultant Advisory Panel review 6/17/2020. (sk)

3/8/22 Reference added. Specialty Matched Consultant Advisory Panel review 6/16/2021. (sk)

7/26/22 Reference added. Specialty Matched Consultant Advisory Panel review 6/29/2022. (sk)

8/01/23 Reference added. Minor edits to Description section. Specialty Match Consultant Advisory Panel review 6/2023. Medical Director review 6/2023. (rp)

7/17/24 Reference added. Specialty Matched Consultant Advisory Panel review 6/2024. Medical Director review 6/2024. (rp)