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Coverage criteria policies

Spinal unloading devices

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is not applicable for spinal unloading devices because they are considered investigational/experimental. The provider and facility will be liable for payment unless:

  1. The provider notifies the member that a specific service has been determined by HealthPartners to be investigational/experimental; and
  2. The member signs a waiver agreeing to pay for the specific non-covered service being rendered; and
  3. The claim has been billed with a GA modifier indicating such. If the member has signed a waiver agreeing to pay for the specific service then the member will be liable for payment.


Spinal unloading devices are considered investigational/experimental and are therefore not covered.


Patient operated spinal unloading devices are intended for use by individuals with chronic low-back pain who have failed standard medical or surgical treatment. These devices provide a traction-like effect by shifting weight bearing off the lower back and onto the hips, either by using applied pneumatic pressure or the gravitational force provided by the patient’s own body mass.

Some examples of these devices include, but are not limited to the Saunders Home Traction Device, Orthotrac Pneumatic Vest and the LTX 3000 Lumbar Rehabilitation System.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.




Ambulatory traction device, all types, each


Durable Medical Equipment, miscellaneous

CPT Copyright American Medical Association. All rights reserved.  CPT is a registered trademark of the American Medical Association.


  1. Hayes, Inc. Hayes Medical Technology Directory Report. Spinal unloading devices for low back pain. Lansdale, PA: Hayes, Inc.; September, 2001. Reviewed August 2006, Archived January 2007.
  2. Hahne, AJ, Ford JJ, McMeeken, JM. Conservative management of lumbar disc herniation with associated radiculopathy: A systematic review. Spine. 2010; 35(11):E488-E504.
  3. North American Spine Society (NASS). Diagnosis and treatment of degenerative lumbar spinal stenosis. Burr Ridge, IL: North American Spine Society (NASS); 2011.


This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy contact Member Services at 952-883-7979 or 1-800-233-9645.

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Policy activity

  • 08/03/2004 - Date of origin
  • 08/03/2004 - Effective date
Review date
  • 08/2018

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