CurrentKaiser PermanentePolicy N/A

Vertebral Axial Decompression (VAX-D) / Internal Disc Decompression (IDD)

Clinical review criteria for coverage and medical necessity determinations for vertebral axial decompression (VAX-D), Spina/IDD systems, and related spinal traction therapies for Kaiser Permanente Washington members.

Policy Summary

PayerKaiser Permanente

PolicyVertebral Axial Decompression (VAX-D) / Internal Disc Decompression (IDD)

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionIf requesting this service, submit the last 6 months of clinical notes from the requesting provider and/or specialist to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not coveredMedicare coverage stance (NCD 160.16)

Not coveredNon‑Medicare coverage stance

20 sessionsTypical treatment course

n=778Largest cited case series

S9090HCPCS status

Coverage and Medical Necessity

Policy Summary

PayerKaiser Permanente

PolicyVertebral Axial Decompression (VAX-D) / Internal Disc Decompression (IDD)

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionIf requesting this service, submit the last 6 months of clinical notes from the requesting provider and/or specialist to support medical necessity.

SourceLink

On This Page

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Coverage summary

Covered when ALL of the following are met:

Overall coverage stance: Medicare: VAX-D/internal disc decompression is not covered per NCD 160.16. Non‑Medicare: Kaiser Permanente uses MCG Traction, Spine (A-0345) criteria and MCG guidance indicates the service is not covered; the medical technology assessment concluded the published evidence is insufficient to demonstrate effectiveness.

Based on CMS NCD 160.16 for Medicare members and MCG guidance for non‑Medicare members; MTAC and literature review found insufficient evidence (case series and limited RCT data).

Investigators who evaluated vertebral axial decompression (VAX-D) and Spina/IDD devices identified specific contraindications for patient selection. Documented contraindications include cauda equina syndrome, active infection, tumor, severe osteoporosis, fractures, bilateral pars defect, spondylolisthesis Grade 2, and the presence of surgical hardware at the treatment site. These contraindications were reported by device investigators as conditions for which VAX-D/Spina IDD should not be used.

Kaiser Permanente's Medical Technology Assessment concluded that use of VAX-D and Spina IDD systems for chronic low back pain does not meet the Medical Technology Assessment criteria because the published evidence is insufficient to demonstrate effectiveness. The evidence base is dominated by uncontrolled case series (including a large series of n=778) and a small number of studies with important methodological limitations; statistical analyses, follow‑up completeness, and comparative data versus natural history are lacking.

Critical appraisal found no high‑quality, consistent randomized controlled trial data demonstrating net health benefit. The MTAC review explicitly states that the best published evidence is insufficient to determine whether benefits of VAX‑D outweigh harms and therefore does not support routine use. As a result, the policy lists vertebral axial decompression (HCPCS S9090) as considered not medically necessary.

Codes and Typical Regimen

Considered Not Medically Necessary HCPCSHCPCSNot Covered

S9090

Vertebral axial decompression, per session

Typical treatment sessions

Typical number of sessionsApproximately 20 sessions (average course)

Cycles per session (VAX-D)About 15 distraction–relaxation cycles per session (≈1 minute distraction, 1 minute relaxation)

Session duration (Spina/IDD)Each Spina/IDD session lasts approximately 30 minutes

Treatment timeframe (Spina/IDD)Typical Spina/IDD regimen: 20 sessions over ~35 days

Typical tension range (VAX-D)Therapeutic tension range 50–95 pounds, reduced by 10–15 pounds if patient becomes asymptomatic or plateaus

Prior Authorization, Documentation, and Billing Guidance

Prior Authorization

Prior Authorization and Affected Codes

Prior authorization not required for Medicare members when service is non‑covered by NCD; for non‑Medicare members, medical necessity determinations follow MCG Traction, Spine (A‑0345). If you need the specific MCG criteria used in a review, contact Kaiser Permanente Clinical Review staff at 1‑800‑289‑1363 or access the MCG Guideline Index via the provider portal.

MCG Guideline: Traction, Spine (A‑0345) — applies to non‑Medicare determinations
Medicare: NCD 160.16 — Vertebral Axial Decompression (VAX‑D) — not covered

Documentation Required

Required Documentation for Requests

If requesting this service, include the last 6 months of clinical notes from the requesting provider and/or specialist to support medical necessity.

Include: last 6 months of clinical notes from requesting provider and/or specialist

Denial Risk

Coverage Denial Triggers — Medicare NCD and Non‑Medicare Guidance

Vertebral axial decompression (VAX‑D) / traction services are considered not medically necessary per policy guidance — billing for non‑covered services may be denied. For Medicare members this is based on NCD 160.16; for non‑Medicare members this follows MCG guidance.

Not medically necessary / not covered: S9090 — Vertebral axial decompression, per session
Medicare: NCD 160.16 — VAX‑D not covered
Non‑Medicare: per MCG Traction, Spine (A‑0345) — service not covered

Note

Provider Action Required

Action required: when a patient is under review and you request the specific MCG criteria used, contact Kaiser Permanente Clinical Review at 1‑800‑289‑1363 to obtain the criteria for that individual member.

Kaiser Permanente Clinical Review: 1‑800‑289‑1363
Access MCG Guideline Index via provider portal under Quick Access

Clinical Background

Chronic low back pain arises from multiple potential anatomic sources, including degenerative disc disease, herniated discs, and facet syndrome, and frequently lacks a direct correlation between imaging findings and symptoms. Vertebral axial decompression therapies are intended to reduce intradiscal pressure by applying automated or controlled distraction‑relaxation forces to the lumbar spine over a course of treatments. Typical device protocols reported in the evidence consist of approximately 20 sessions; for VAX‑D these are delivered as about 15 automated distraction‑relaxation cycles per session with tensions in the 50–95 lb range, and the Spina/IDD system is described as delivering static/intermittent cyclic distraction over ~20 sessions (about 30 minutes each) across ~35 days.

Device Definitions and Typical Protocols

VAX-D system description and typical course

Device description (VAX-D)Vertebral axial decompression table with split design; patient lies prone, upper body on stationary portion, pelvic harness attached to a tensionometer to apply automated distraction–relaxation cycles

Cycle characteristics (VAX-D)Automated distraction–relaxation cycles (~15 cycles per session) with continuous feedback recorded on a tensionometer/chart

Force/tension parameters (VAX-D)Therapeutic tensions 50–95 lbs, reduced by 10–15 lbs when symptoms remit or plateau

Patient positioning and safety (VAX-D)Patient restrained by handgrips (may release at any time); operator monitors tensionometer printout during treatment

Typical course (VAX-D)Average course of therapy is ~20 sessions

Spina/IDD system description and typical regimen

Device description (Spina/IDD)Non‑invasive system consisting of a split table (two cushions) and a controller unit that applies static, intermittent, and cyclic distraction forces via a pelvic harness

Typical regimen20 treatment sessions delivered over a period of ~35 days

Session lengthEach session lasts approximately 30 minutes

Indication statementIntended to relieve pressure on structures causing chronic neck or lower back pain