CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Lumbar Artificial Intervertebral Disc Replacement (Total Disc Replacement) Coverage Criteria

Policy governs coverage determination for single-level lumbar total disc replacement for commercial members of Blue Cross Blue Shield - Rhode Island; it does not apply to BlueCHiP for Medicare which has a separate policy.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyLumbar artificial intervertebral disc replacement (total disc replacement) — Commercial Products

Policy CodePolicy N/A

Change TypeNo material change

Effective DateSep 1, 2005

Next Review DateN/A

Key ActionDo not bill members for services determined not medically necessary; verify member benefits and eligibility.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not medically necessaryCommercial coverage stance

Single interspaceFDA indication

5-year outcomesRCT follow-up

CPT 22857Primary procedure code

Coverage Determination

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Commercial Products - Coverage Determination

Covered when ALL of the following are met:

Commercial coverage: Artificial intervertebral disc replacement of the lumbar spine is considered not medically necessary for Commercial Products because the evidence is insufficient to determine the effects of the technology on health outcomes.

RCTs with 5-year outcomes show noninferiority in some trials but long-term benefits and complication rates remain uncertain.

Patients being considered for lumbar artificial intervertebral disc replacement must not have any of the following exclusionary characteristics: multilevel disease, spinal stenosis, spondylolisthesis, scoliosis, a history of previous major spine surgery, or current neurologic symptoms. Patients who require additional procedures (for example, laminectomy or other decompression) are also not candidates for artificial disc replacement. These contraindications restrict eligibility to a subset of patients with single-level degenerative disc disease who have failed conservative therapy.

For Commercial Products, artificial intervertebral disc replacement of the lumbar spine is considered not medically necessary. This determination applies to the primary procedure code CPT 22857 and the related add-on and revision codes 0163T, 0165T, and 22862.

Procedure and Billing Codes

Not medically necessary CPT codes - primaryCPTNot Covered

22857

Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), lumbar, single interspace

Not medically necessary CPT codes - add-on/revisionCPTNot Covered

0163T	Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), lumbar, each additional interspace
0165T	Revision of total disc arthroplasty, anterior approach, lumbar; each additional interspace
22862	Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, lumbar, single interspace

Provider Actions and Billing Guidance

Prior Authorization

Prior Authorization Required

Prior authorization is Not applicable for this policy. Providers do not need to request prior authorization for services described in this policy.

Note

Billing Rule

Provider Billing and Member Eligibility

Verify member-specific benefits and eligibility prior to providing services. Do not bill members for services determined to be not medically necessary unless the member has been informed and provided written agreement to pay out-of-pocket in advance.

Denial Risk

PROVIDER ACTIONS — Denial Risk for Lumbar Artificial Disc Replacement

Claims for lumbar artificial intervertebral disc replacement (including CPT 22857 and related add-on/revision codes such as 0163T, 0165T, 22862) are considered not medically necessary and are subject to denial.

Affected codes: 22857, 0163T, 0165T, 22862

Background

Total disc replacement (also called spinal arthroplasty) is a surgical procedure that replaces a damaged lumbar intervertebral disc with an artificial device intended to preserve motion at the operative level as an alternative to spinal fusion. It has been developed because fusion can alter spinal biomechanics and may accelerate adjacent-level degeneration; artificial discs aim to maintain motion but carry risks including device failure, bone–implant interface failure, and adverse host responses. Use of artificial discs has been studied mainly for carefully selected patients with single-level degenerative disc disease (DDD) who have disabling symptoms and have not improved with conservative care, but long-term benefits and complication rates remain uncertain.

Definitions

Degenerative disc disease (DDD) — definition and suitability for single-level disc replacement

DefinitionDiscogenic back pain with degeneration of the disc confirmed by patient history and radiographs; suitable for single-level disc replacement when contraindications (multilevel disease, spinal stenosis, spondylolisthesis, scoliosis, prior major spine surgery, neurologic symptoms) are absent.

PopulationSkeletally mature patients with degenerative disc disease (DDD) at a single interspace (one level).

Exclusions / Unsuitable featuresMultilevel disease, spinal stenosis, spondylolisthesis, scoliosis, previous major spine surgery, neurologic symptoms, or need for additional procedures (eg, laminectomy, decompression) — these make patients not candidates for artificial disc replacement.

Clinical contextCandidates have chronic low back pain attributed to DDD and have failed nonoperative treatment; artificial disc replacement is an alternative to fusion for this subset of patients.

Risks relevant to suitabilityUse of a motion-preserving artificial disc increases potential implant-related complications (device fracture/dislocation/wear, bone-implant interface failure, osteolysis, heterotopic ossification, pseudotumor).

Total disc replacement / spinal arthroplasty — procedure definition and intent

Procedure definitionSurgical implantation of an artificial intervertebral disc (total disc replacement or spinal arthroplasty) intended to maintain or preserve motion at the operative level after removal of the damaged disc.

Intent / RationaleOffered as a motion-preserving alternative to spinal fusion to avoid altered biomechanics and potential adjacent-level degeneration associated with fusion.

Indicated device scopeDevices approved by FDA for spinal arthroplasty are indicated for single-level DDD in skeletally mature patients; long-term effectiveness and safety remain uncertain and approvals have included postmarketing study requirements.

Potential device issuesArtificial discs carry risks including device failure (fracture, dislocation, wear), bone-implant interface failure (subsidence, migration, vertebral fracture), and adverse host responses (osteolysis, heterotopic ossification, pseudotumor formation).

Candidate selection noteOnly a subset of fusion candidates are appropriate for disc replacement — must lack contraindications and not require additional procedures beyond disc replacement.