S9090 — Vertebral axial decompression, per session
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- No specific clinical documentation requirements, prior authorization criteria, or medical necessity documentation requirements for motorized spinal traction are specified in this policy.
- General instruction: 'When deciding coverage, the member specific benefit plan document must be referenced as the terms of the member specific benefit plan may differ from the standard plan. In the event of a conflict, the member specific benefit plan document governs. Before using this policy, please check the member specific benefit plan document and any applicable federal or state mandates.'
- General instruction: UnitedHealthcare may use tools developed by third parties, such as the InterQual® criteria, to assist in administering health benefits (i.e., check member-specific processes/tools for documentation requirements).
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
16 Active Policies
THE803.021 — Vertebral Axial Decompression
CIGNA-CPG135 — Physical Therapy - (CPG135)
CIGNA-CPG275 — Axial/Spinal Decompression Therapy/Mechanical Traction (Provided in a Clinic Setting) - (CPG275)
CIGNA-CPG278 — Chiropractic Care - (CPG278)
AETNA-CPB-0180 — Vertebral Axial Decompression
Related Codes
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