BlueCross BlueShield of Tennessee Medical Policy Manual

Spinal Unloading Devices for the Treatment of Low Back Pain

DESCRIPTION

The goal of traction is to separate the space between vertebral bodies to unload the spine and decompress discs, alleviate pain and support healing. Self-operated devices for lumbar spinal unloading are available for use at home and include pneumatic systems (e.g., Orthotrac Pneumatic Vest™, STx™ Saunders Lumbar Traction Device, Saunders Lumbar Hometrac™ Deluxe) and gravity-dependent devices (e.g., LTX 3000™). These 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.

POLICY

IMPORTANT REMINDERS

ADDITIONAL INFORMATION 

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

SOURCES 

Agency for Healthcare Research and Quality. (2016, November). Noninvasive treatments for low back pain: current state of the evidence. Retrieved April 26, 2019 from https://effectivehealthcare.ahrq.gov/.

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.

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.

North American Spine Society. (2012). Evidence-based clinical guidelines for multidisciplinary spine care. Diagnosis and treatment of degenerative lumbar spinal stenosis. Retrieved June 5, 2018 from www.spine.org.

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:  5/9/2019

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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