Artificial Intervertebral Disc Replacement

Policy ID: S-9007-03

Section: Surgery

Effective Date: July 01, 2018

Revised Date: February 05, 2024

Revision Effective Date: May 06, 2024

Last Reviewed: March 19, 2024

Applies To: Commercial and Medicaid Expansion

Description

Cervical Artificial Disc:

Several prosthetic devices are currently available for artificial intervertebral disc arthroplasty (AIDA) of the cervical spine. AIDA is proposed as an alternative to anterior cervical discectomy and fusion (ACDF) for individuals with symptomatic cervical degenerative disc disease (DDD).

Lumbar Artificial Disc:

A lumbar disk replacement substitutes a mechanical device for an intervertebral disk in the lumbar spine. The device is meant to restore motion to the spine by replacing the worn, degenerated disk.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

Cervical artificial intervertebral disc replacement or spinal arthroplasty may be considered medically necessary when performed at either a single level or two levels in individuals with symptomatic cervical degenerative disc disease (e.g., radicular neck and/or arm pain and/or functional/neurological deficit) or herniated disc when ALL of the following criteria are met:

Use of an FDA approved device and at least ONE of the following confirmed by radiographic studies (e.g., CT, MRI, x-rays)
- Herniated nucleus pulposus; or
- Spondylosis defined by presence of osteophytes; or
- Visible loss of disc height (not more than 50%) as compared to adjacent levels; and
The operative level is either a single level or two levels from C3 to C7; and
The individual has not had a prior spinal fusion at an adjacent cervical level; and
The procedure is performed in a skeletally mature individual; and
The individual has failed at least six weeks of physician monitored/supervised conservative management which includes ALL of the following components:
- Exercise including core stabilization exercises; and
- Nonsteroidal and/or steroidal medication (unless contraindicated); and
- Physical therapy, including passive and active treatment modalities; and
- Activity/lifestyle modification

Cervical artificial intervertebral disc replacement is considered experimental/investigational, and therefore non-covered, when ALL of the above criteria are not met.

Procedure Codes

22856

22858

22861

22864

0095T

0098T

Lumbar intervertebral disc replacement or spinal arthroplasty may be considered medically necessary when performed at one-level when ALL of the following criteria are met:

<82>
One-level degenerative disc disease (DDD) from L4-S1 as shown on CT or MRI; and
Failure of 3 months of conservative therapy including BOTH of the following:
- A trial of non-steroidal anti-inflammatories (NSAIDs); and
- A documented trial of up to six-weeks of physical therapy; and
The individual is between 18-65 years old; and
Symptoms are localizable to one-level in the L4-S1 area; and
Absence of moderate or severe facet joint arthropathy confirmed by CT or MRI.

Lumbar artificial intervertebral disc replacement is considered experimental/investigational and therefore non-covered when ALL of the above criteria are not met.

Procedure Codes

22857

22860

22862

22865

Cervical artificial intervertebral disc replacement is considered experimental/investigational, and therefore non-covered, when disc implantation is performed at more than two levels. The safety and/or effectiveness of this procedure cannot be established by the available published peer-reviewed literature.

Lumbar artificial intervertebral disc replacement is considered experimental/investigational, and therefore non-covered, when disc implantation is performed at more than one-level because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Codes

0164T

0165T

Artificial disc replacement at one-level combined with spinal fusion surgery at another level, commonly referred to as hybrid surgery, is considered experimental/investigational and therefore non-covered. There is a lack of scientific-based evidence of long-term studies demonstrating the safety and efficacy of this procedure.

Thoracic artificial intervertebral disc replacement for the thoracic spine is considered experimental/investigational and therefore, non-covered due to insufficient evidence in the peer reviewed published literature regarding its effectiveness and safety. There are currently no FDA approved devices to support thoracic artificial disc replacement.

Procedure Codes

22899

Diagnosis Codes

COVERED DIAGNOSIS CODES FOR PROCEDURE CODES 22856, 22861, 22864, 22858, 0095T, and 0098T.

M50.01

M50.020

M50.021

M50.022

M50.023

M50.11

M50.121

M50.122

M50.123

M50.13

M50.20

M50.21

M50.220

M50.221

M50.222

M50.223

M50.30

M50.31

M50.320

M50.321

M50.322

M50.323

M50.80

M50.81

M50.820

M50.821

M50.822

M50.823

M50.90

M50.923

M50.920

M50.921

M50.922

COVERED DIAGNOSIS CODES FOR PROCEDURE CODES 22857, 22862 AND 22865

M51.06

M51.16

M51.17

M51.26

M51.36

M51.37

M51.86

M51.87

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 11-14-2019 HMK archived, review by Evicore. Assoc has 2 separate policies. Denies Lumbar INV. ND had criteria for both lumbar and cervical.

Internal Medical Policy Committee 01-29-2021 Coding update-

Removed Procedure code 0375T.

Internal Medical Policy Committee 01-20-2022 Annual Review

Internal Medical Policy Committee 11-29-2022 Coding update - Effective January 1, 2022

Added procedure code 22860.

Internal Medical Policy Committee 1-26-2023 Annual Review - no changes in criteria

Internal Medical Policy Committee 1-19-2024 Coding update - Effective May 06, 2024

Removed procedure code 0163T, and
Added diagnosis codes M50.13, M50.20, M50.30, M50.80, M50.81, M50.90, M51.26, M51.86, & M51.87

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: S-9007-02

Section: Surgery

Effective Date: July 01, 2018

Revised Date: December 02, 2022

Revision Effective Date: January 01, 2023

Last Reviewed: January 26, 2023

Archived Date: May 05, 2024

Applies To: Commercial and Medicaid Expansion

Description

Cervical Artificial Disc:

Lumbar Artificial Disc:

A lumbar disk replacement substitutes a mechanical device for an intervertebral disk in the lumbar spine. The device is meant to restore motion to the spine by replacing the worn, degenerated disk.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person’s unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

Use of an FDA approved device and at least ONE of the following confirmed by radiographic studies (e.g., CT, MRI, x-rays)
- Herniated nucleus pulposus; or
- Spondylosis defined by presence of osteophytes; or
- Visible loss of disc height (not more than 50%) as compared to adjacent levels; and
The operative level is either a single level or two levels from C3 to C7; and
The individual has not had a prior spinal fusion at an adjacent cervical level; and
The procedure is performed in a skeletally mature individual; and
The individual has failed at least six weeks of physician monitored/supervised conservative management which includes ALL of the following components:
- Exercise including core stabilization exercises; and
- Nonsteroidal and/or steroidal medication (unless contraindicated); and
- Physical therapy, including passive and active treatment modalities; and
- Activity/lifestyle modification

Cervical artificial intervertebral disc replacement is considered experimental/investigational, and therefore non-covered, when ALL of the above criteria are not met.

Procedure Codes

22856

22858

22861

22864

0095T

0098T

Lumbar intervertebral disc replacement or spinal arthroplasty may be considered medically necessary when performed at one-level when ALL of the following criteria are met:

One-level degenerative disc disease (DDD) from L4-S1 as shown on CT or MRI; and
Failure of 3 months of conservative therapy including BOTH of the following:
- A trial of non-steroidal anti-inflammatories (NSAIDs); and
- A documented trial of up to six-weeks of physical therapy; and
The individual is between 18-65 years old; and
Symptoms are localizable to one-level in the L4-S1 area; and
Absence of moderate or severe facet joint arthropathy confirmed by CT or MRI.

Lumbar artificial intervertebral disc replacement is considered experimental/investigational and therefore non-covered when ALL of the above criteria are not met.

Procedure Codes

22857

22860

22862

22865

Procedure Codes

0163T

0164T

0165T

Procedure Codes

22899

Diagnosis Codes

COVERED DIAGNOSIS CODES FOR PROCEDURE CODES 22856, 22861, 22864, 22858, 0095T, 0098T

M50.01

M50.020

M50.021

M50.022

M50.023

M50.11

M50.121

M50.122

M50.123

M50.21

M50.220

M50.221

M50.222

M50.223

M50.31

M50.320

M50.321

M50.322

M50.323

M50.820

M50.821

M50.822

M50.823

M50.920

M50.921

M50.922

M50.923

COVERED DIAGNOSIS CODES FOR PROCEDURE CODES 22857, 22862 AND 22865

M51.06

M51.16

M51.17

M51.36

M51.37

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 11-14-2019 HMK archived, review by Evicore. Assoc has 2 separate policies. Denies Lumbar INV. ND had criteria for both lumbar and cervical.

Internal Medical Policy Committee 01-19-2021 Coding update-Removed Procedure code 0375T

Internal Medical Policy Committee 01-20-2022 Annual Review

Internal Medical Policy Committee 11-29-2022 Coding update-Effective January 1, 2022

Added procedure code 22860

Internal Medical Policy Committee 1-26-2023 Annual Review - no changes in criteria

Links

References (PDF)

Disclaimer

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