CurrentEmblemHealthPolicy MG.MM.SU.46fC3

Artificial Intervertebral Discs

Defines medical necessity, coverage criteria, and coding for FDA‑approved cervical and lumbar artificial disc replacement for members with single‑level lumbar or 1–2 contiguous cervical level disease; applies to providers requesting prior authorization from EmblemHealth.

Policy Summary

PayerEmblemHealth

PolicyArtificial Intervertebral Discs

Policy CodePolicy MG.MM.SU.46fC3

Change TypeNo material changes

Effective Date

Next Review DateNov 8, 2024

Key ActionSubmit prior authorization with clinical documentation demonstrating the patient meets all coverage criteria before coverage is determined.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

single‑level lumbar or 1–2 cervicallevels eligible for coverage

VAS > 40pain score threshold

Oswestry/NDI > 30disability score threshold

≥6 monthsconservative treatment req

7 codesprocedure codes listed

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Coverage Criteria for Artificial Disc Replacement

Prior spinal fusion or other spinal surgery at the affected level is an exclusion to coverage. Requests for insertion in the presence of a current or previous fracture at the affected level are also excluded. Additionally, insertion when there is an active infection at the operative site is contraindicated and will not meet coverage criteria. These conditions should be clearly documented in the medical record and will be reviewed during prior authorization.

Artificial discs are not medically necessary when used for indications that are not FDA‑approved (off‑label use) or when implanted despite contraindications listed in the device’s product labeling. Other situations that render the procedure not medically necessary include prior fusion or other spinal surgery at the affected level, current or prior fracture at the level, or presence of infection. Discogram is only indicated for the lumbar region.

Relevant Procedure and Diagnosis Codes

Applicable Procedure CodesCPT

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 (other than for decompression), single interspace, lumbar.
22858	Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation; second level, cervical (add-on).
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 Codes (selection)ICD-10

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 60

1/6

inv-06: Visual Analog Scale (VAS) — pain score threshold

Visual Analog Scale (VAS) thresholdPain score > 40 on Visual Analog Scale (VAS)

ContextRequired as part of severity criteria for coverage of artificial disc replacement

Documentation neededProvider must submit VAS score in prior authorization documentation (physician progress notes)

inv-07: Oswestry / NDI disability score threshold

Oswestry/NDI thresholdDisability score > 30 on Oswestry Low Back Pain Disability Questionnaire or Neck Disability Index

ContextRequired along with VAS > 40 as part of severity criteria for coverage

Documentation neededProvider must submit Oswestry or NDI score in prior authorization documentation (physician progress notes)

Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required. The treating physician or primary care provider must submit clinical documentation proving the patient meets all criteria before EmblemHealth can make a coverage determination. Without the required documentation, EmblemHealth will be unable to properly review the request for prior authorization.

Submit request before service; prior authorization required
EmblemHealth will not review without complete clinical evidence

Documentation Required

Documentation to Submit

Providers must submit clinical evidence demonstrating that the patient meets the guideline criteria. Required documentation includes, but is not limited to: confirmation of skeletal maturity, radiologic confirmation of disease (e.g., CT or MRI, and discogram where indicated), physician progress notes documenting pain location confined to operative level(s), validated pain and disability scores, and detailed records of prior conservative therapies.

Background on Artificial Disc Replacement

Artificial disc replacement is an FDA‑approved surgical option for skeletally mature patients with symptomatic degenerative disc disease or cervical degenerative disc disease at specified levels. Devices are implanted between vertebrae to replace diseased or damaged discs and differ by labeled indications and approved levels; clinicians must follow device labeling and FDA indications when considering candidates for surgery. Note that certain conditions — including prior fusion or surgery at the target level, fractures, and infection — are exclusions to coverage and may preclude use of an artificial disc.

Definitions

inv-14: Definition — Artificial discs (device composition and purpose)

CompositionDevices constructed from metal, plastic, titanium or polyurethane implanted between spinal vertebrae

PurposeReplacement for diseased/damaged discs to provide relief for intractable pain

PlacementSurgically implanted between the vertebrae as an intervertebral disc replacement

inv-15: Definition — Cervical degenerative disc disease (CDD)

DefinitionNeck or arm (radicular) pain and/or a functional/neurological deficit with at least one imaging-confirmed condition (herniated nucleus pulposus, spondylosis/osteophytes, or loss of disc height)

Confirmatory imagingCT or X-rays (and MRI for loss of disc height) required to confirm underlying condition