CurrentEmblemHealthPolicy MG.MM.SU.46g

Artificial Intervertebral Discs

EmblemHealth clinical guideline defining medical necessity criteria, eligible devices/indications, exclusions/limitations, and applicable procedure and diagnosis codes for cervical and lumbar artificial disc replacement (single-level lumbar or single/1-2 contiguous cervical levels) in skeletally mature patients.

Policy Summary

PayerEmblemHealth

PolicyArtificial Intervertebral Discs

Policy CodePolicy MG.MM.SU.46g

Change TypeRevisions and clarifications (device levels, contraindications, diagnostic prerequisites)

Effective Date

Next Review Date

Key ActionTreating physician/PCP must submit clinical evidence that the patient meets all coverage criteria (imaging, VAS and disability scores, ≥6 months conservative therapy with ≥2 modalities) to EmblemHealth for prior authorization review.

SourceLink

POLICY UPDATE CHANGES

Removed discogram prerequisite prior to disc replacement (Oct. 10, 2025).

Removed prerequisite for grade/millimeter measurement of spondylolisthesis; added presence of infection as a surgical contraindication (Oct. 8, 2021).

Clarified that discogram is only indicated for the lumbar region; removed 'No nerve root compression or narrowing of lateral access' as prerequisite (Oct. 12, 2018).

Expanded coverage for 1-2 contiguous cervical levels (e.g., Mobi-C®) (Dec. 9, 2016).

Single-level lumbar or 1-2 contiguous cervicalCovered Levels

≥6 monthsConservative therapy

VAS ≥40Pain threshold

Coverage Summary

Scope: EmblemHealth guideline defining medical necessity criteria, eligible devices/indications, exclusions/limitations, and applicable procedure and diagnosis codes for cervical and lumbar artificial disc replacement. Coverage is limited to skeletally mature patients and to FDA-approved indications and device labeling. Overview: This policy covers single-level lumbar disc replacement or single or 1-2 contiguous cervical levels in skeletally mature patients, when all clinical criteria (imaging confirmation, pain and disability thresholds, and conservative therapy requirements) and device labeling/FDA indications are met.

Quick facts & thresholds

Pain threshold (Visual Analog Scale)VAS ≥ 40

Disability threshold (Oswestry or NDI)Oswestry/NDI ≥ 30

Conservative therapy durationFailure of ≥ 6 months consistent conservative medical therapy

Conservative modalities requiredDocumentation that ≥ 2 of: physical therapy, chiropractic care, ice/heat therapy, pharmacotherapy (e.g., NSAIDs, muscle relaxants, epidural/facet injections) were tried

Covered anatomic levelsSingle‑level lumbar or 1–2 contiguous cervical levels

Skeletal maturity and imagingSkeletally mature with disease confirmed by CT or MRI and pain confined to operative level(s)

Medical‑Necessity Criteria

Applicable Codes

Applicable Procedure Codes (CPT)CPTCovered

22856	Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation, single interspace, cervical
22857	Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace, single interspace, lumbar
22858	Total disc arthroplasty; second level, cervical (list separately in addition to code for primary procedure)
22861	Revision including replacement of total disc arthroplasty, anterior approach, single interspace; cervical
22862	Revision including replacement of total disc arthroplasty, anterior approach, single interspace; lumbar
22864	Removal of total disc arthroplasty, anterior approach, single interspace; cervical
22865	Removal of total disc arthroplasty, anterior approach, single interspace; lumbar

Applicable ICD-10 Diagnosis CodesICD-10Covered

M47.16	Other spondylosis with myelopathy, lumbar region
M47.26	Other spondylosis with radiculopathy, lumbar region
M47.27	Other spondylosis with radiculopathy, lumbosacral region
M47.816	Spondylosis without myelopathy or radiculopathy, lumbar region
M47.817	Spondylosis without myelopathy or radiculopathy, lumbosacral region
M47.896	Other spondylosis, lumbar region
M47.897	Other spondylosis, lumbosacral region
M48.36	Traumatic spondylopathy, lumbar region
M48.37	Traumatic spondylopathy, lumbosacral region
M50.00	Cervical disc disorder with myelopathy, unspecified cervical region

1–10 of 62

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Provider Actions & Prior Authorization

Prior Authorization

Prior authorization and documentation submission

The treating physician must submit clinical evidence that the patient meets ALL coverage criteria for artificial disc replacement to EmblemHealth for prior authorization review. This documentation should demonstrate: confirmed disease by imaging, pain confined to the operative level(s), VAS pain score ≥ 40, disability score ≥ 30 (Oswestry or Neck Disability Index), failure of ≥ 6 months of consistent conservative medical therapy, and trials of at least two conservative modalities. EmblemHealth will not review or approve requests without these materials.

Radiologic imaging confirming disease (CT or MRI)
Documentation that pain is confined to operative level(s)
Visual Analog Scale (VAS) pain score ≥ 40
Disability score ≥ 30 on Oswestry Low Back Pain Disability Questionnaire or Neck Disability Index
Physician office progress notes documenting ≥ 6 months of conservative therapy and trials of ≥ 2 modalities (see Conservative therapy documentation)
Any device-specific contraindications or prior surgical history

Background & Evidence

Background: Artificial discs are prosthetic devices surgically implanted to replace diseased intervertebral discs to provide relief from intractable pain. Coverage is limited to skeletally mature individuals with disease confirmed by radiological imaging (CT or MRI) and who meet the policy’s functional and pain thresholds and conservative therapy requirements. Devices must be used in accordance with their FDA-approved indications and labeling; specific device labeling may include level restrictions and contraindications. Limitations: The policy excludes use when device insertion is for non–FDA‑approved purposes, when product‑label contraindications apply (including presence of infection), after prior fusion or surgery at the affected level, or with current/prior fracture at the level. Recent revisions noted removal of a routine discogram prerequisite and clarification of spondylolisthesis measurement requirements.

Evidence summary

Unsupported block type: paragraph

Definitions

Unsupported block type: definition

Revision History

Oct. 10, 2025material_changeLatest

Removed discogram prerequisite prior to disc replacement.

Oct. 8, 2021material_change

Removed prerequisite for grade/millimeter measurement of spondylolisthesis; added presence of infection as a surgical contraindication.

Oct. 12, 2018material_change

Clarified that discogram is only indicated for the lumbar region; removed 'No nerve root compression or narrowing of lateral access' as prerequisite.