S9090, Vertebral axial decompression, per session
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Medicare Pricing
Documentation Required
- No explicit documentation requirements are specified in this Clinical Policy Bulletin.
- Implied/typical documentation (NOT specified in CPB): diagnosis, treatment plan, records of supervised traction sessions, and clinical rationale would be relevant, but the CPB does not state required documentation elements.
- No specific documentation requirements are stated in this policy bulletin.
- Documentation of failure of other evidence-based therapeutic procedures to resolve symptoms after 3 weeks.
- For cervical traction: documentation of a diagnosis of cervical radiculopathy AND documentation that at least 3 of the following 5 findings are present: patient-reported peripheralization with lower cervical spine (C4-7) mobility testing; positive shoulder abduction test; age >= 55; positive upper limb tension test A; positive neck distraction test.
- For lumbar traction: documentation of sciatica or signs of nerve root compression AND documentation of either peripheralization with extension movements or a positive crossed straight leg raise test.
Key Coverage Criteria
- Inferred (from policy text): Supervised mechanical lumbar traction provided by physicians or physical therapists as part of conservative treatment for low back pain (typically delivered in conjunction with other therapeutic procedures) — standard treatment described as up to 4 sessions per week.
- Note: The policy addresses lumbar traction devices generally but does NOT list any specific device-based indications as medically necessary; instead it identifies numerous device types as experimental/investigational (see Limitations).
- Cervical mechanical traction is considered medically necessary in the clinic setting for patients who meet ALL of the following criteria: Failure of other evidence-based therapeutic procedures to resolve symptoms after 3 weeks; Only used in combination with other evidence-based treatments including therapeutic exercise (the therapeutic exercise(s) should not cause aggravation or peripheralization of symptoms); Patient has cervical radiculopathy diagnosis with at least 3 of the following findings [...]
- Lumbar mechanical traction is considered medically necessary in the clinic setting for patients who meet ALL of the following criteria: Failure of other evidence-based therapeutic procedures to resolve symptoms after 3 weeks; Only used in combination with other evidence-based treatments including therapeutic exercise with extension movements (the therapeutic exercise(s) should not cause aggravation or peripheralization of symptoms); Patient has sciatica or signs of nerve root compression and eit [...]
- When the above criteria are met, CPT 97012 (Application of a modality to 1 or more areas; traction, mechanical) is considered medically necessary.
- The service is aimed at diagnosis, and treatment of musculoskeletal and related disorders and the effects of these on the nervous system and general health
17 Active Policies
THE803.021, Vertebral Axial Decompression
ANTHEM-SURG.00008, SURG.00008 Mechanized Spinal Distraction Therapy
UHC-POL-motorized-spinal-traction, Motorized Spinal Traction
AETNA-CPB-0569, Lumbar Traction Devices
AETNA-CPB-0180, Vertebral Axial Decompression
BCBSIL-THE803.021, Vertebral Axial Decompression
BCBSMT-THE803.021, Vertebral Axial Decompression
BCBSNM-THE803.021, Vertebral Axial Decompression
CARELON-physical-therapy-occupational-therapy-and-speech-therapy-2024-04-14, Physical Therapy Occupational Therapy and Speech Therapy
BCBSOK-THE803.021, Vertebral Axial Decompression
REGENCE-MED45, Vertebral Axial Decompression
UMR-POL-UMR-motorized-spinal-traction, Motorized Spinal Traction
SUREST-POL-SUREST-motorized-spinal-traction, Motorized Spinal Traction
CIGNA-CPG275, Axial/Spinal Decompression Therapy/Mechanical Traction (Provided in a Clinic Setting)
CIGNA-CPG278, Chiropractic Care
CIGNA-CPG135, Physical Therapy
EVICORE-HPLAN-HAP-AB9D421BCDBD, Health Alliance Plan MSK Code List - Effective 01/01/2026
Related Codes
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