CurrentAetnaPolicy 0569

Lumbar Traction Devices

This policy governs the coverage stance for lumbar traction devices and related traction interventions for low back pain (LBP) and other indications for Aetna members. It identifies devices considered experimental/investigational and cross-references related Aetna policies.

Policy Summary

PayerAetna

PolicyLumbar Traction Devices

Policy CodePolicy 0569

Change TypeNo material change

Effective DateNov 9, 2001

Next Review DateJun 13, 2024

Key ActionDocument clinical rationale and concurrent therapies when traction is provided; note that devices listed as experimental/investigational may be denied.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6+device types listed as experimental/investigational

97012, E0830example CPT/HCPCS codes mentioned

4standard sessions/week

83.2%positive response in Tadano et al.

Coverage Criteria for Lumbar Traction Devices

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Experimental/Investigational interventions

Device types considered experimental/investigational
- Autotraction devices (brand examples: Anatomotor, Arthrotonic stabilizer, Quantum 400 inter-segmental traction table, Spinalator Spinalign massage inter-segmental traction table).
- Home pneumatic lumbar traction devices (e.g., Orthotrac Pneumatic Vest; Saunders Lumbar HomeTrac; Saunders STx; DDS 500 Lumbar Traction).
- Axial spinal unloading (gravity-dependent traction) devices (e.g., LTX 3000; Triton DTS; Z-Grav Spinal Decompression Table).
- Lumbar lordotic curve-controlled traction devices (e.g., Kinetrac-9900).
- Inversion tables (e.g., Fit Spine LX9 inversion table).

HCPCS and related codes for traction devices are identified in the policy. Notably, E0830 is listed for ambulatory traction devices, L0631 is listed for a lumbar‑sacral orthosis (sagittal control), and S9090 is listed for vertebral axial decompression (per session; e.g., Triton DTS). The policy also references CPT procedure codes commonly used with traction services such as 97012 (mechanical traction) and 97140 (manual therapy techniques, including manual traction).

The policy explicitly notes that certain HCPCS-coded devices (examples given include the Z‑Grav spinal decompression table, lumbar lordotic curve‑controlled traction devices, and inversion tables such as the Fit Spine LX9) are not covered for the indications listed in this Clinical Policy Bulletin; use or billing for these devices may be subject to denial because effectiveness has not been established.

A randomized study of lordotic curve‑controlled traction (Lee et al.) had several important limitations described by the authors. Although enrollment met sample‑size targets, the study population was narrowly defined and may not generalize to broader age groups or disease severities. There was no control group of patients without disc disease, and outcomes were assessed immediately after a course of therapy (final measurement at ~15 sessions, about 1.5 months), so the trial did not provide data on durable, long‑term benefit. The authors conclude that the long‑lasting effects of traction remain undetermined and should be assessed in future studies.

Systematic reviews and authoritative assessments consistently conclude that the available evidence does not demonstrate traction to be effective for acute or chronic low back pain. Earlier technology assessments and guidelines (for example, the Norwegian Centre for Health Technology Assessment and AHCPR guideline) reported no demonstrated benefit for traction in lumbar disc herniation or acute LBP. More recent systematic reviews, including a Cochrane review, found that traction is probably not effective overall and that neither continuous nor intermittent traction alone was superior to placebo, sham, or other treatments for mixed‑duration low back pain with or without sciatica. Some reviews noted isolated findings (for example, limited evidence that autotraction may be superior to mechanical traction in certain sciatica outcomes), but these results were inconsistent and based on studies with methodological limitations.

Relevant CPT/HCPCS/ICD-10 Codes

Related CPT codesCPT

97012	Application of a modality to one or more areas; traction, mechanical.
97140	Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes.

HCPCS codes mentioned (not covered for CPB indications)HCPCSNot Covered

E0830	Ambulatory traction device, all types, each.
L0631	Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise.
S9090	Vertebral axial decompression, per session [Triton DTS].

ICD-10 codes mentioned (not covered for CPB indications)ICD-10

M54.50	Low back pain
M54.59	Low back pain

Provider Actions, Prior Authorization & Documentation

Prior Authorization

Prior Authorization May Apply

Prior authorization may apply to listed CPT/HCPCS codes for traction devices and services. Verify PA requirements with the member's plan before provision or billing.

Affected codes: CPT 97012, 97140; HCPCS E0830, L0631, S9090

Denial Risk

Denial Risk for Experimental/Investigational Devices

Use or billing for devices and procedures listed as experimental and investigational may result in claim denial. Examples include autotraction devices, home pneumatic lumbar traction devices (e.g., Orthotrac, Saunders HomeTrac), axial spinal unloading devices (e.g., LTX 3000, Triton DTS), lumbar lordotic curve-controlled traction devices (e.g., Kinetrac-9900), and inversion tables (e.g., Fit Spine LX9).

Autotraction devices (Anatomotor, Arthrotonic stabilizer, Quantum 400, Spinalator Spinalign)
Home pneumatic lumbar traction devices (Orthotrac, Saunders Lumbar HomeTrac, Saunders STx, DDS 500)
Axial spinal unloading devices (LTX 3000, Triton DTS, Z-Grav Spinal Decompression Table)
Lumbar lordotic curve-controlled traction devices (Kinetrac-9900)
Inversion tables (Fit Spine LX9)

Documentation Required

Documentation When Traction Is Used

Document the clinical rationale when traction is used, including indication, type of traction, force/intensity, frequency and duration of sessions, and concurrent therapies (e.g., physical therapy modalities).

Record indication and objective findings (e.g., diagnosis, imaging when applicable)
Specify traction type (manual, mechanical, pneumatic, autotraction, inversion, etc.)
Document traction parameters: force/intensity, continuous vs intermittent, session length, frequency
Note concurrent treatments provided during the same course of care

Step Therapy

No step therapy requirements are described in this policy.

Note

Clinical Studies Summarized; No Submission Requirements Specified

This document summarizes clinical studies and investigational findings related to lumbar traction (e.g., Tadano et al. 2019; Lee et al. 2020) but does not specify submission requirements for studies or additional provider actions beyond documentation and prior authorization checks.

Summaries describe limited evidence and methodological concerns regarding traction effectiveness
No study submission or exception request procedures are specified in this portion of the policy

Note

Provider Actions Not Specified in This Part of the Document

No other provider actions or specific operational steps are specified in this portion of the document. Check the payer's plan-specific requirements and related policy documents for additional instructions.

Related policies: CPB 0180, CPB 0232, CPB 0453 may contain additional guidance
Verify member-specific benefit and prior authorization rules

Background on Traction Therapies

Traction is widely used in the management of low back pain in multiple forms and modes, including mechanical traction, manual traction, autotraction (use of the patient’s own weight), gravity‑dependent or axial unloading devices, pneumatic systems, and continuous or intermittent application. Its proposed mechanisms—such as spinal elongation, reduction of lordosis, or increased intervertebral space—have been offered, but empirical support is limited. Traction is commonly administered in combination with other therapies, and supervised mechanical traction is typically provided up to 4 sessions per week in clinical practice.

Definitions

Autotraction (definition and examples)

DefinitionAutotraction is the use of one’s own weight to create the traction force, allowing the patient to determine traction force and enabling positional and gravity‑assisted multi‑plane traction.

Mechanism/examplesDelivered via tables with custom‑contoured rollers that move beneath the patient (e.g., Spinalator, Spinalign Massage, Intersegmental Traction Table, Anatomotor). A 3‑motor system can control roller elevation, travel, and rotation.

Clinical evidenceOnly two randomized clinical trials compare autotraction with other traction forms; results are conflicting (Telso & Merlo 1993 showed favorable response to autotraction; Ljunggren et al. 1984 found no difference).

Typical useApplied as one form of lumbar traction, often in combination with other therapies for low back pain; patients control force via positioning and gravity effects.

Spinal unloading devices (definition)

DefinitionSpinal unloading devices are systems that provide a traction‑like effect to shift weight‑bearing off the lower back and onto the hips, using various methods to reduce lumbar loading.

MechanismsSome devices use the individual’s body mass/gravitational force (e.g., LTX 3000); others use applied pneumatic pressure (e.g., Orthotrac Pneumatic Vest, Saunders Lumbar Traction devices, Saunders Hometrac Deluxe).

Example device (manufacturer claim)DDS 500 Lumbar Traction uses a spinal air‑traction design with vertically expandable columns to provide traction and spinal decompression between the lower rib cage and upper hip, and converts to a soft LSO for flexibility.

Regulatory noteThese devices have been cleared by the FDA via 510(k) premarket notification; clinical effectiveness evidence to support improved patient outcomes is lacking.