BlueCross BlueShield of Tennessee Medical Policy Manual

Spinal Unloading Devices for the Treatment of Low Back Pain

DESCRIPTION

Patient-operated spinal unloading devices have been investigated as a conservative, non-invasive treatment option for subacute and chronic low back pain for individuals who have not responded adequately to standard medical therapy. The intent of these devices is to provide a traction-like effect by shifting weight bearing off the lower back and onto the hips. The method used to shift weight bearing varies among devices. Some devices (e.g., LTX 3000™) utilize gravitational force provided by the body mass of the individual. The LTX 3000 consists of an adjustable seat strap and rib support pads that purportedly stabilize the upper body by engaging the lowest portion of the rib cage. After the rib support pads have been properly adjusted, the individual lowers the seat strap to induce unloading of the lumbar spine via the downward force provided by the individual’s body mass.

Other devices (e.g., Orthotrac Pneumatic Vest™, STx™ Saunders Lumbar Traction Device, and Saunders Lumbar Hometrac™ Deluxe) utilize applied pneumatic pressure in an effort to shift weight bearing off the lower back.

POLICY

IMPORTANT REMINDERS

ADDITIONAL INFORMATION 

There is insufficient evidence from peer-reviewed published studies to conclude that axial spinal unloading devices are effective in the management of low back pain.

SOURCES 

American College of Physicians. (2017). Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Retrieved July 21, 2017 from http://annals.org/aim/article/2603228/noninvasive-treatments-acute-subacute-chronic-low-back-pain-clinical-practice.

Institute for Clinical Systems Improvement. (2012). Adult acute and subacute low back pain. Retrieved May 30, 2014 from www.icsi.org.

National Institute for Health and Care Excellence. (2016). Low back pain and sciatica in over 16s: assessment and management. Retrieved July 21, 2017 from www.nice.org.uk/guidance/ng59.

U. S. Food and Drug Administration. (2008, April). Center for Devices and Radiological Health. Code of Federal Regulations: Title 21: Volume 8: 21CFR888.5850: Part 888 Orthopedic Devices: Section 888.5850. Nonpowered orthopedic traction apparatus and accessories. Retrieved February 9, 2009 from http://frwebgate6.access.gpo.gov/cgi-bin/PDFgate.cgi?WAISdocID=213296488427+1+2+0&WAISection=retrieve.

ORIGINAL EFFECTIVE DATE:  7/1/2002

MOST RECENT REVIEW DATE:  8/10/2017

ID_BT

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

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