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Decompression Therapy

Section: Therapy
Effective Date: July 01, 2018
Revised Date: May 14, 2018
Last Reviewed: November 14, 2019

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.

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.

Criteria

Coverage is subject to the specific terms of the member’s benefit plan.

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.

Procedure Codes

S9090

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.

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