CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Total disc replacement (lumbar artificial intervertebral disc) - Commercial Products

State commercial products coverage policy for lumbar total disc replacement (artificial intervertebral discs) describing medical necessity stance, applicable CPT/HCPCS codes, background, regulatory status, and related policies. Applies to Commercial Products only; Medicare Advantage has separate guidance.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyTotal disc replacement (lumbar artificial intervertebral disc) - Commercial Products

Policy CodePolicy N/A

Change Typeclarified

Effective DateSep 1, 2005

Next Review Date

Key ActionVerify benefits/eligibility against the member's subscriber agreement or employer contract as benefits may vary between groups/contracts; Benefit Booklet/Evidence of Coverage supersedes this medical policy for coverage determination.

SourceLink

POLICY UPDATE CHANGES

Policy applies to Commercial Products only; Medicare Advantage plans have separate related policy.

1Primary CPT code listed

3Codes not medically necessary

Commercial onlyApplicability

Coverage Summary

Overview: This policy covers lumbar total disc replacement (artificial intervertebral disc) as an alternative to spinal fusion for patients with persistent, disabling degenerative disc disease. It summarizes medical necessity determinations, applicable procedure codes, background, regulatory status, and related policies relevant to Commercial Products.

Applicability note: Policy applies to Commercial Products only. For Medicare Advantage Plans, see the separate Medicare Advantage National and Local Coverage Determinations policy guidance.

Key policy dates and scope

Effective date2005-09-01

Policy last reviewed2021-04-21

Next review

StatusCURRENT (Commercial Products) - Artificial lumbar discs considered not medically necessary

ApplicabilityCommercial Products only; Medicare Advantage has separate related policy

Primary CPT code listed22857 (total disc arthroplasty, lumbar, single interspace)

Not medically necessary / Not covered additional/revision codes0163T, 22862, 0165T

Medical‑Necessity Criteria

Medical Necessity Determination

Policy statements for Commercial Products:

Artificial intervertebral discs of the lumbar spine are considered not medically necessary for Commercial Products because evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Medicare Advantage Plans

Separate related policy applies:

For Medicare Advantage Plans, see related policy section for the Medicare Advantage Plans National and Local Coverage Determinations policy.

Coding — Not Medically Necessary / Not Covered

Covered CPT (primary procedure) - considered not medically necessary under Commercial ProductsCPTNot Covered

22857

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

Not medically necessary / Not covered procedure codes (additional/add-on/revision codes)mixedNot Covered

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

Coding note: The primary CPT code 22857 and related add-on/revision codes (for example, 0163T, 22862, 0165T) are declared not medically necessary for Commercial Products under this policy.

Medicare Advantage separate guidance: Medicare Advantage Plans have separate coding and coverage guidance; see the related Medicare Advantage National and Local Coverage Determinations policy.

Provider Actions

Documentation Required

Benefit verification and member-specific coverage

Verify benefits/eligibility against the member's subscriber agreement or employer contract as benefits may vary between groups/contracts; Benefit Booklet/Evidence of Coverage supersedes this medical policy for coverage determination.

Billing Rule

Do not charge member for non-covered services without written consent

If services are determined to be not medically necessary (or are non-covered benefits), the provider may not charge the member unless the member was informed and agreed in writing in advance to continue treatment at their own expense.

Prior Authorization

Prior authorization not applicable in policy

The policy states 'Not applicable' under Prior Authorization for Commercial Products; however providers should follow any plan-specific preauthorization processes referenced in related policies.

Background & Evidence

Background: Lumbar total disc replacement (artificial intervertebral disc) is intended to preserve motion at a diseased lumbar disc level as an alternative to spinal fusion for patients with degenerative disc disease (DDD) who have chronic low back pain, have failed conservative treatment, and have no contraindications (for example multilevel disease, spinal stenosis, spondylolisthesis, scoliosis, prior major spine surgery, or need for additional decompression).

Regulatory and evidence context: Several devices (activL, ProDisc-L, Charite) received FDA premarket approval; approvals were contingent on postmarketing studies. Although randomized trials (for example ProDisc-L) have shown noninferiority to fusion at 5 years and some early superiority at 2 years, long-term effectiveness and harms remain uncertain, and evidence is insufficient to conclude an improvement in net health outcome.

Study / Evidence	Summary
ProDisc-L randomized controlled trials
Five-year RCT outcomes demonstrated noninferiority to fusion; superiority at 2 but not at 5 years; uncertainty about long-term benefits and harms remains.
activL evidence
No RCTs comparing activL to spinal fusion or conservative care identified in policy.

Degenerative disc disease (DDD): Discogenic back pain with degeneration of the disc confirmed by patient history and radiographs.

Name	Number	Effective Year
Lumbar Artificial Disk Replacement (LADR)
10.1
2007

Revision History

2005-09-01effective_date

Policy effective date established (EFFECTIVE DATE: 09|01 2005).

2005-09-01document_scope_clarification

Policy applies to Commercial Products only; Medicare Advantage Plans have separate related policy.

2005-09-01coverage_stance

Artificial intervertebral discs of the lumbar spine are considered not medically necessary for Commercial Products because evidence is insufficient to determine improvement in net health outcome.

2021-04-21last_reviewLatest

Policy last updated/reviewed on 04/21/2021.