This policy version was replaced May 30, 2022. To find the newest version, go to https://www.bluecrossmn.com/providers/medical-policy-and-utilization-management, read and accept the Blue Cross Medical Policy Statement, then select “Blue Cross and Blue Shield of Minnesota Medical Policies.” This will bring up the Medical Policy search screen. Enter the policy number without the version number (last 3 digits).
Various traction decompression systems have been proposed as non-surgical outpatient forms of treatment for conditions of the spine such as herniated discs, bulging or protruding discs, degenerative disc disease, posterior facet syndrome, and sciatica. These include traction decompression and intersegmental traction or autotraction tables. Traction decompression systems include but are not limited to the Vertebral Axial Decompression table (VAX-D®), Accu-Spina™ System, Decompression Reduction Stabilization (DRS®) System, DRX3000®, DRX5000®, DRX9000®, Dynatron DX2™, Lordex® Lumbar Spine System, Healthstar Elite Decompression Therapy, SpineMED®, SpineRx-LDM (lumbar decompression machine), Saunders 3D ActiveTrac®, and the Tru-Trac® Traction Unit. Examples of intersegmental traction tables include the Anatomotor, the Arthrotonic stabilizer, the Quantum 400 inter-segmental traction table, and the Spinalator Spinalign massage inter-segmental traction table.
The systems generally provide a program of treatments that are designed to provide static, intermittent, and cycling distraction forces to the spine in an effort to relieve back pain. Each session typically includes 10-20 decompression-relaxation cycles. The patient undergoes multiple sessions over the course of several weeks.
Traction decompression therapy of the spine is considered EXPERIMENTAL/INVESTIGATIVE due to a lack of clinical evidence demonstrating an impact on improved health outcomes.
No additional statements.
Blue Cross and Blue Shield of Minnesota medical policies apply generally to all Blue Cross and Blue Plus plans and products. Benefit plans vary in coverage and some plans may not provide coverage for certain services addressed in the medical policies. When determining coverage, reference the member’s specific benefit plan, including exclusions and limitations.
Medicaid products may provide different coverage for certain services, which may be addressed in different policies. For Minnesota Health Care Program (MHCP) policies, please consult the MHCP Provider Manual website.
Medicare products may provide different coverage for certain services, which may be addressed in different policies. For Medicare National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and/or Local Coverage Articles, please consult CMS, National Government Services, or CGS websites.
Note that services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial of claims may result if criteria are not met.
Blue Cross and Blue Shield of Minnesota reserves the right to revise, update and/or add to its medical policies at any time without notice. Codes listed on this policy are included for informational purposes only and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement.
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Acknowledgements:
CPT® codes copyright American Medical Association® 2022. All rights reserved.
CDT codes copyright American Dental Association® 2022. All rights reserved.
