Intervertebral Disc Prosthesis (Total Disc Arthroplasty)
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Medical necessity and coverage criteria for FDA‑approved cervical and lumbar intervertebral disc prostheses, including prior authorization documentation and coding, for Eocco members.
No material clinical or coverage changes in this revision.
Coverage Criteria for Intervertebral Disc Prosthesis
inv-01: Cervical — Medically Necessary
Covered when ALL of the following are met for FDA‑approved cervical prosthetic discs:
Contraindications/exclusions listed separately
inv-02: Lumbar — Medically Necessary
Covered when ALL of the following are met for FDA‑approved lumbar prosthetic discs:
Contraindications/exclusions listed separately
inv-03: Investigational / Experimental
Limitations
The following conditions are explicit contraindications or exclusions to coverage for intervertebral disc prosthesis and must be confirmed prior to authorization. Devices are NOT covered for: more than two cervical levels requiring surgical treatment; a fused level adjacent to the level to be treated or a planned adjacent-level fusion; evidence of cervical instability on dynamic flexion‑extension radiographs such as sagittal‑plane translation > 3.5 mm or sagittal‑plane angulation > 20° at a single level; diagnosis of osteoporosis, osteopenia, or osteomalacia; spinal metastases; severe facet joint disease or facet ankylosis/severe facet arthrosis at the involved level; active systemic infection or imaging confirming infection at the implantation site; known allergies or sensitivity to implant materials (stainless steel, titanium, titanium alloy, cobalt/chromium/molybdenum, polyethylene); chronic steroid use; pregnancy; morbid obesity; prior lumbar fusion or planned simultaneous multilevel lumbar implantation; imaging evidence of spinal tumor, multiple levels of degenerative disc disease, degenerative spondylolisthesis Grade ≥2, pars interarticularis defects/spondylolysis or isthmic spondylolisthesis, nerve root compression or lumbar spinal stenosis, lumbar scoliosis, or spinal fracture.
Confirming these exclusions against the member’s history and recent imaging is required because requests will be denied when contraindications listed above are present or when other key criteria (appropriate levels, imaging confirmation, conservative therapy, prior surgeries) are not met.
Any use of prosthetic intervertebral disc devices for indications not explicitly listed as covered in this policy is considered experimental and investigational. Authorization requests for devices being studied in clinical trials will be reviewed case‑by‑case; the device under study is considered investigational and is not covered by the plan (the trial typically covers the cost of the implant).
Procedure and Diagnosis Coding
| 22856 | Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection) |
| 22857 | Total disc arthroplasty (artificial disc), anterior approach, single interspace, cervical |
| 22858 | Total disc arthroplasty (artificial disc), anterior approach, single interspace, lumbar |
| 22860 | Total disc arthroplasty (artificial disc), anterior approach; second interspace, lumbar (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, lumbar, single interspace |
| 0095T | Removal of total disc arthroplasty, anterior approach, each additional interspace, cervical (list separately in addition to code for primary procedure) |
| 0098T | Revision including replacement of total disc arthroplasty, anterior approach, each additional interspace, cervical (list separately in addition to code for primary procedure) |
| G54.2 | Cervical root disorders, not elsewhere classified [nerve root/spinal cord compression] |
| G54.9 | Nerve root and plexus disorder, unspecified [nerve root/spinal cord compression] |
| M50.00-M50.03 | Cervical disc disorder with myelopathy [nerve root/spinal cord compression] |
| M50.10-M50.13 | Cervical disc disorder with radiculopathy [nerve root/spinal cord compression] |
| M50.20-M50.23 | Other cervical disc displacement |
| M50.30-M50.33 | Other cervical disc degeneration |
| M51.36 | Other intervertebral disc degeneration, lumbar region |
| M51.37 | Other intervertebral disc degeneration, lumbosacral region |
| M53.1 | Cervicobrachial syndrome [with findings of weakness, myelopathy, or sensory deficit] |
Prior Authorization, Documentation, and Denial Triggers
Submit prior authorization with clinical notes, imaging, conservative therapy history, and device requested
Prior authorization is required for intervertebral disc prosthesis procedures and must be submitted before coverage determination. The request must include: physician chart notes, imaging studies (CT or MRI performed within the last 6 months), documentation of conservative treatment history, and the specific type of artificial disc being requested. The policy’s covered CPT/HCPCS codes should be included with the request.
- Physician chart notes from the treating clinician
- Advanced imaging (MRI or CT) confirming diagnosis performed within the last 6 months
- Documentation of conservative treatment attempts and duration
- Specification of the artificial disc/device requested
- Relevant CPT/HCPCS code(s) from the policy (e.g., 22856, 22857, 22858, 22860, 22861, 22862, 22864, 22865, 0095T, 0098T, 0164T, 0165T)
Document required conservative nonoperative therapy (cervical ≥2 months; lumbar ≥6 months)
Conservative nonoperative therapy must be attempted and documented before authorization: cervical cases require at least 2 months of conservative treatment and lumbar cases require at least 6 months. The time requirement can be waived if the patient is experiencing progressive neurological worsening despite nonoperative treatment.
- Cervical: ≥2 months of conservative therapy with 2 or more modalities (e.g., NSAIDs/analgesics/steroids, physical therapy, epidural steroid injection/selective nerve root blocks)
- Lumbar: ≥6 months of conservative therapy including NSAIDs/analgesics/steroids, physical therapy, and epidural steroid injections/selective nerve root blocks
- Waiver allowed for progressive neurologic worsening
Include chart notes, recent imaging, conservative treatment records, and device type with the request
Required documentation submitted with the prior authorization must include treating physician chart notes, radiographic studies (MRI or CT within 6 months), documentation of conservative treatment attempts, and the type of artificial disc being requested.
- Treating physician chart notes describing history, exam, and rationale for disc replacement
- CT or MRI reports/images performed within the last 6 months confirming degenerative disc disease at the involved level(s)
- Records of conservative treatment attempts and durations (modalities used and response)
- Specification of the device/artificial disc model being requested
Denial risk if criteria, imaging, conservative therapy, device approval, or surgical history are not met
Requests will be denied if the submitted documentation does not meet policy criteria, including absence of FDA‑approved device indication, incorrect operative levels, insufficient or outdated imaging, inadequate documented conservative therapy, or presence of listed contraindications or prior surgeries.
- Device not FDA‑approved for the requested cervical or lumbar level
- Operative levels exceed policy limits (e.g., >2 cervical levels; more than one lumbar level)
- Imaging not provided or not performed within the required 6‑month window confirming degenerative disease
- Inadequate documentation of required conservative therapy duration or modalities
- Prior fusion at the involved level(s) or other contraindications listed in the policy (e.g., Grade ≥2 spondylolisthesis for lumbar, osteoporosis/osteopenia, active infection, planned adjacent fusion)
Background
Total disc arthroplasty (artificial intervertebral disc) is a surgical alternative to spinal fusion in which a diseased disc is replaced with a prosthetic device intended to preserve motion at the treated level. The procedure is offered as a means to maintain segmental mobility and may potentially reduce adjacent‑level degeneration compared with fusion, but long‑term outcomes and device durability remain under study and revision surgery may be required for device wear or progression of adjacent disease.
Because evidence is evolving, coverage in this policy is limited to FDA‑approved cervical and lumbar prosthetic discs when all specified clinical criteria, imaging findings, and documentation requirements are met; devices under investigation or uses outside the stated indications are considered investigational.
Definitions
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