CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

total_disc_replacement_medical_necessity_policy

Policy governs medical necessity and coverage determination for lumbar artificial intervertebral disc replacement (total disc replacement) for Commercial Products of Blue Cross Blue Shield Rhode Island. It states the procedure is considered not medically necessary for Commercial members and references separate BlueCHiP for Medicare policy.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

Policytotal_disc_replacement_medical_necessity_policy

Policy CodePolicy N/A

Change Typeclarified

Effective DateSep 1, 2005

Next Review Date

Key ActionVerify member's benefits in the Benefit Booklet, Evidence of Coverage or Subscriber Agreement as benefits may vary between groups/contracts; these documents supersede this policy for member-specific coverage.

SourceLink

POLICY UPDATE CHANGES

Policy applies to Commercial Products only; BlueCHiP for Medicare has a related separate policy.

4CPT/HCPCS codes listed as not medically necessary

Commercial onlyApplicability

2005-09-01Policy effective date

2019-05-21Last updated

This policy governs lumbar artificial intervertebral disc replacement (total disc replacement) for Commercial Products and states the procedure is not medically necessary for Commercial members.

Total disc replacement is an alternative to fusion for lumbar degenerative disc disease intended to preserve motion; candidates are a subset of patients without contraindications such as multilevel disease, spinal stenosis, spondylolisthesis, scoliosis, prior major spine surgery, and neurologic symptoms.

Long-term safety and effectiveness remain uncertain and there is potential for device-related complications (eg, device failure, bone-implant interface failure, host response to the implant), contributing to the determination of not medically necessary for Commercial coverage.

Policy dates and applicability

Effective Date2005-09-01

Last Review2019-05-21

ApplicabilityCommercial Products only

Policy stanceNot medically necessary for Commercial products (procedure considered not medically necessary; evidence insufficient to determine effects on health outcomes)

OpenPayer

total_disc_replacement_medical_necessity_policy

Coverage Summary