Artificial intervertebral disc replacement - cervical

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

Administrative process

Prior authorization is required for artificial cervical intervertebral disc replacement.

Artificial cervical intervertebral disc replacement is generally covered subject to the indications listed below and per your plan documents. (Lumbar artificial intervertebral disc replacement is not addressed in this policy. Please see related content at the right for link to Lumbar artificial intervertebral disc replacement.

Indications that are covered

Artificial cervical intervertebral disc may be considered medically necessary upon meeting all of the following criteria:

1. Intractable radiculopathy and/or myelopathy should present with at least one of the following items producing symptomatic nerve root and/or spinal cord compression which is documented by member history:
   
   1. Herniated disc; AND/OR
   2. Osteophyte formation
2. Member must be skeletally mature; AND
3. Member must have tried and failed at least 6 weeks of conservative management (including rest, application of heat /ice, physical therapy, exercise, pain and/or anti-inflammatory medications); AND
4. Member history should include documentation of: neck and/or arm pain, functional and/or neurological deficits, and radiographic studies such as CT, MRI, x-rays; AND
5. Cervical area being replaced and reconstructed is within discs C3-C7, and involves either a single-level or a 2-level discectomy for intractable radiculopathy and/or myelopathy; AND
6. Device must be FDA approved for both the condition being treated and for the number of levels being treated.

Indications that are not covered

Artificial cervical intervertebral disc is not covered for members with any of the following conditions:

1. Active systemic infection or infection at the surgical site; OR
2. Allergy to any of the device materials; OR
3. Osteopenia or osteoporosis; OR
4. Marked cervical instability on radiographs, defined as subluxation >3.5mm or angulation of the disc space >11 degrees greater than adjacent segments; OR
5. Moderate to advanced spondylosis, characterized by bridging osteophytes, marked reduction or absence of motion, or collapse of the intervertebral disc space of > 50% of its normal height; OR
6. Presence of significant facet arthropathy at the level to be treated (index level); OR
7. Significant cervical anatomical deformity or clinically compromised vertebral bodies at the level to be treated due to systemic disease, previous surgery, or trauma; OR
8. Significant kyphotic deformity, significant reversal of lordosis, or significant spondylolisthesis; OR
9. Single disc replacement(s) at more than one cervical level is planned; OR
10. Disc replacement(s) for symptoms necessitating concurrent additional surgical treatment (i.e. fusion); OR
11. Disc replacement(s) for cervical level adjacent to a previous cervical fusion.

Arthroplasty is the surgical repair of a joint.

Artificial cervical intervertebral disc replacement, also known as cervical disc arthroplasty, is a procedure which replaces a degenerated cervical (neck) disc with a prosthetic disc. Artificial cervical intervertebral disc replacement is intended as an alternative to anterior cervical discectomy and fusion surgery. The artificial disc is intended to relieve pain, restore disc height, maintain motion of the natural spine, and prevent degeneration of adjacent discs.

Examples of an artificial cervical spinal disc include: The Prestige® Cervical Disc System by Medtronic, the Bryan® Cervical Disc System by Medtronic, and the ProDisc®-C by Synthes Spine, and The Mobi-C by LDR Spine USA Inc. (Mobi-C for single-level disc replacement or Mobi-C for 2 level total disc replacement).

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.

22856 - Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end
plate preparation (includes osteophytectomy for nerve root or spinal cord
decompression and microdissection), single interspace, cervical
22861 - Revision including replacement of total disc arthroplasty (artificial disc), anterior
approach, single interspace; cervical
22864 - Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace;
cervical
0092T - Total disc arthroplasty (artificial disc), anterior approach, including discectomy with
end plate preparation (includes osteophytectomy for nerve root or spinal cord
decompression and microdissection), each additional interspace, cervical
0095T - Removal of total disc arthroplasty (artificial disc), anterior approach, each additional
interspace, cervical
0098T - Revision including replacement of total disc arthroplasty (artificial disc), anterior
approach, each additional interspace, cervical

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

This information is for most, but not all, CoOportunity Health 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.

CoOportunity Health has contracted with HealthPartners Administrators, Inc. to provide claims processing, medical management and certain other administrative services.