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Artificial Intervertebral Disc Replacement

Section: Surgery
Effective Date: July 01, 2018
Revised Date: November 14, 2019
Last Reviewed: November 14, 2019

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 patients 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:

  • · 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 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.

Procedure Codes

0375T

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

0163T 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, 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

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