CurrentevicorePolicy CMM-601

Anterior Cervical Discectomy and Fusion

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Defines medical necessity criteria and procedural requirements for initial and repeat anterior cervical discectomy and fusion (ACDF), anterior cervical corpectomy with fusion, and related indications (radiculopathy, myelopathy, pseudoarthrosis, implant failure) for Cigna members; intended for providers requesting authorization or performing surgery.

Policy Summary

Payerevicore

PolicyAnterior Cervical Discectomy and Fusion

Policy CodePolicy CMM-601

Change TypeNo material changes

Effective DateAug 4, 2026

Next Review Date

Key ActionObtain prior authorization and document imaging, conservative therapy trials (typically ≥6 weeks), and nicotine-free status (or cotinine test) when requesting ACDF, repeat ACDF, or corpectomy with fusion.

SourceLink

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CurrentevicorePolicy CMM-601

Anterior Cervical Discectomy and Fusion

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Policy Summary

Payerevicore

PolicyAnterior Cervical Discectomy and Fusion

Policy CodePolicy CMM-601

Change TypeNo material changes

Effective DateAug 4, 2026

Next Review Date

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>=6 wksconservative therapy (min)

>=6 mospost-op imaging interval

6 wksnicotine abstinence

Performed with fusionfusion requirement

Page 29codes table

39document pages

Coverage Criteria — Anterior Cervical Procedures

Initial Primary ACDF (Radiculopathy or Myelopathy)

Initial primary anterior cervical discectomy and fusion (ACDF) is considered medically necessary when performed for EITHER of the following conditions when ALL of the associated criteria have been met:

Indications

Radiculopathy: Symptoms: BOTH of (1) significant daily pain causing clinically significant functional impairment (e.g., inability to perform household chores, prolonged standing) AND (2) unremitting radicular pain to the shoulder girdle and/or upper extremity resulting in disability. Physical exam: ANY of dermatomal sensory deficit, motor deficit (e.g., biceps/triceps weakness), reflex changes, shoulder abduction relief sign, nerve root tension sign (e.g., Spurling's), OR unremitting radicular pain without concordant objective findings. Imaging: MRI/CT demonstrates neural structure compression at the requested level(s) concordant with symptoms caused by herniated disc (including retained/recurrent disc material), synovial or arachnoid cyst, central/lateral/foraminal stenosis, or osteophytes. Prior therapy: less than clinically meaningful improvement with at least TWO conservative measures unless contraindicated: (a) prescription-strength analgesics/steroids/gabapentinoids/NSAIDs for six (6) weeks; (b) provider-directed exercise program for six (6) weeks; (c) epidural steroid injection(s) or selective nerve root block(s) at the same level(s). Plain radiographs including flexion/extension lateral views performed. Absence of unmanaged significant mental/behavioral health disorders. Documentation of nicotine-free status: never-smoker OR refrained from smoking/use of smokeless tobacco/nicotine replacement for at least six (6) weeks prior to planned surgery validated by objective cotinine testing (serum, urine, or saliva) within the laboratory normal range.
Myelopathy: Symptoms: ANY of upper/lower extremity weakness, numbness or pain, fine motor dysfunction (e.g., buttoning, handwriting), gait disturbance, new-onset bowel or bladder dysfunction, or frequent falls. Physical exam: ANY of grip-and-release impairment, ataxic gait, hyperreflexia, Hoffmann sign, Babinski sign, tandem walking ataxia, inverted brachial radial reflex, increased tone/spasticity, clonus, or myelopathic hand. Imaging: MRI/CT shows cervical spinal cord compression or cervical spinal stenosis concordant with the individual's symptoms and physical exam findings. Absence of unmanaged significant mental/behavioral health disorders. Documentation of nicotine-free status as described for radiculopathy.

Anterior Cervical Corpectomy with Fusion

Anterior cervical corpectomy with fusion is considered medically necessary and can be performed as an alternative for ACDF when ALL of the following criteria have been met:

Corpectomy criteria: Complete or partial corpectomy (removal of at least one-half of the vertebral body; not for osteophyte resection alone) performed for infection, trauma, tumor, or compression at/behind the vertebral body. Procedure must be performed with cervical fusion due to iatrogenic instability. Applicable ACDF criteria (procedure‑specific indications) have been met for the clinical scenario being treated.

Repeat ACDF at Same Level

Repeat anterior cervical discectomy and fusion (ACDF) at the same level is considered medically necessary when performed for ANY of the following conditions when ALL of the associated criteria have been met:

Repeat ACDF Indications

Malposition/Failure of Implant/Instrumentation or Structural Bone Graft: Post-operative imaging documents malposition or failure of implant/instrumentation or structural bone graft (e.g., migration, screw breakage/loosening, dislodged hooks, rod breakage/bending/loosening, loss of curve correction, decompensation).
Unremitting Neck Pain with Pseudoarthrosis: >6 months since prior ACDF at the same level; significant daily pain causing functional impairment; post-operative physical exam concordant with symptoms; lack of clinically meaningful improvement with BOTH: (1) prescription-strength analgesics/steroids/gabapentinoids/NSAIDs for six (6) weeks AND (2) provider-directed exercise program for six (6) weeks; post-operative imaging (performed no less than six (6) months after prior fusion) demonstrates pseudoarthrosis at the requested level(s); post-operative MRI/CT findings concordant with symptoms; absence of unmanaged significant mental/behavioral health disorders; documentation of nicotine-free status (never-smoker OR >=6 weeks abstinent validated by objective cotinine testing).

Adjacent Segment Disease — ACDF considered medically necessary

ACDF for a degenerative spinal segment adjacent to a previous decompression or fusion procedure is considered medically necessary when EITHER of the following conditions are met and ALL associated criteria are satisfied:

Radiculopathy: Greater than six (6) months since prior cervical decompression or fusion at an adjacent level; symptoms: BOTH significant daily pain causing functional impairment AND unremitting radicular pain to shoulder girdle and/or upper extremity resulting in disability. Physical exam: ANY of dermatomal sensory deficit, motor deficit, reflex changes, shoulder abduction relief sign, nerve root tension sign, OR unremitting radicular pain without concordant objective findings. Less than clinically meaningful improvement with at least TWO conservative measures (prescription-strength analgesics/steroids/gabapentinoids/NSAIDs for six (6) weeks; provider-directed exercise program for six (6) weeks; and/or epidural steroid injection(s)/selective nerve root block(s)). Imaging: plain radiographs including flexion/extension and MRI/CT show successful decompression/fusion at the prior level and neural structure compression at the requested adjacent level(s) concordant with symptoms caused by herniated disc (retained/recurrent), synovial/arachnoid cyst, central/lateral/foraminal stenosis, or osteophytes. Absence of unmanaged significant mental/behavioral health disorders. Documentation of nicotine-free status: never-smoker OR >=6 weeks abstinent validated by cotinine testing.

Pseudoarthrosis — Radiculopathy or Myelopathy

Criteria for radiculopathy or myelopathy with pseudoarthrosis

Myelopathy with Pseudoarthrosis: Greater than six (6) months since prior ACDF at the same level; symptoms: ANY myelopathic features (upper/lower extremity weakness, numbness or pain, fine motor dysfunction, gait disturbance, new-onset bowel/bladder dysfunction, frequent falls). Physical exam: ANY of the listed myelopathic signs (grip and release, ataxic gait, hyperreflexia, Hoffmann sign, Babinski sign, tandem walking ataxia, inverted brachial radial reflex, increased muscle tone/spasticity, clonus, myelopathic hand). Post-operative imaging (performed no less than six (6) months after the prior cervical fusion) shows pseudoarthrosis at the requested level(s). Post-operative MRI/CT demonstrates findings concordant with symptoms caused by cervical spinal cord compression or cervical spinal stenosis. Documentation and other requirements (absence of unmanaged significant mental/behavioral health disorders; nicotine-free status validated as specified) apply.

Conservative management and indications (evidence discussion excerpt)

Covered when clinical indications and trial of conservative care align with recommendations (partial section — full criteria in other parts of policy).

General guidance: Indication: cervical degenerative disc disease presenting with radiculopathy or myelopathy; supportive subjective symptoms and physical exam findings should be concordant with imaging. Abnormal advanced imaging alone is insufficient.

Non-operative trial: For cervical radiculopathy, most individuals should undergo a 4-6 week course of non-operative treatment prior to surgery.4-6 weeks

Corpectomy performed solely for resection of osteophytes (i.e., removal of less than one-half of the vertebral body or osteophyte resection alone) is not the indicated use for anterior cervical corpectomy. The policy specifies that a complete or partial corpectomy must involve removal of at least one-half of the vertebral body and be performed for infection, trauma, tumor, or compression at or behind the vertebral body; corpectomy performed only to resect osteophytes is therefore excluded.

Anterior cervical discectomy/corpectomy with fusion performed for chronic non-specific neck or arm pain of unknown etiology, or for cervical degenerative disc disease without radiculopathy or myelopathy, is considered not medically necessary. The policy requires documented radiculopathy or myelopathy and applicable procedure-specific criteria for coverage; procedures performed for non-specific pain without those findings are excluded.

Anterior cervical discectomy or corpectomy performed without an accompanying cervical fusion (i.e., performed alone) is considered not medically necessary. The policy explicitly states that these anterior procedures must be performed with fusion when indicated; standalone discectomy/corpectomy is excluded from coverage.

Anterior cervical osteotomy or vertebral column resection (VCR) performed without meeting the General Guidelines and the criteria in CMM-601.2 Osteotomy is considered not medically necessary. The policy requires adherence to the specified guideline criteria for osteotomy/VCR procedures; failure to meet those criteria renders the procedure noncovered.

The North American Spine Society (NASS) guidance cited in the policy lists contraindications for ACDF that include treatment of discogenic axial neck pain and isolated cervical radiculopathy due to foraminal stenosis amenable to simple foraminotomy. The policy therefore indicates that ACDF is not appropriate for these specific clinical presentations.

The referenced chunks in this portion of the document are bibliographic citations and do not contain explicit exclusion or coverage statements themselves; they support the policy and its clinical guidance but are not exclusion language.

Procedures such as ACDF or corpectomy with fusion that are performed without meeting the applicable General Guidelines and the procedure-specific criteria in this policy (including initial fusion, corpectomy, repeat fusion, adjacent segment disease, or fusion following failed disc arthroplasty) are considered not medically necessary. The policy emphasizes that meeting the named criteria is required for coverage.

The policy cites NASS recommendations that list use of ACDF to treat discogenic axial neck pain as a contraindication rather than an appropriate indication for fusion. This bibliographic guidance is incorporated into the policy’s exclusion/contraindication statements.

These cited reference entries do not state explicit additional 'not medically necessary' conditions within the referenced text; they function as literature sources supporting the policy statements elsewhere in the document.

Coding — Procedure and Test Codes

Codes listed in Codes (CMM-601) tableCPT

22220	Osteotomy of spine, including discectomy, anterior approach, single vertebral, Code Description/Definition = 22220.
22548	Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2 (atlas-axis), with or without excision of odontoid process, Code Description/Definition = 22548.
22551	Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots;, Code Description/Definition = 22551.
+22552	Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace (List separately in addition to code for separate procedure), Code Description/Definition = +22552.
22554	Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2, Code Description/Definition = 22554.
+22585	Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (List separately in addition to code for primary procedure), Code Description/Definition = +22585.
+22845	Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure), Code Description/Definition = +22845.

EIU / ACDF-related CPT and add-on codesCPT

22220	Osteotomy of spine, including discectomy, anterior approach, single vertebral
22548	Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2 (atlas-axis), with or without excision of odontoid process
22551	Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots
+22552	Arthrodesis, anterior interbody...cervical below C2, each additional interspace (add-on)
22554	Arthrodesis, anterior interbody technique...cervical below C2
+22585	Arthrodesis, anterior interbody technique...each additional interspace (add-on)
+22845	Anterior instrumentation; 2 to 3 vertebral segments (add-on)
+22846	Anterior instrumentation; 4 to 7 vertebral segments (add-on)
+22853	Insertion of interbody biomechanical device(s) with integral anterior instrumentation, each interspace (add-on)
+22854	Insertion of intervertebral biomechanical device(s) to vertebral corpectomy defect, each contiguous defect (add-on)

1–10 of 15

1/2

inv-19: Conservative therapy duration

Required duration>= 6 weeks of conservative therapy (prescription analgesics/steroids/gabapentinoids/NSAIDs or provider-directed exercise) prior to many surgical indications

Acceptable therapiesPrescription-strength analgesics/steroids/gabapentinoids/NSAIDs; provider-directed exercise program; epidural steroid injection or selective nerve root block (where specified)

Documentation neededProvider documentation must show lack of clinically meaningful improvement after the required therapies

inv-20: Post-operative imaging interval for pseudoarthrosis

Minimum interval>= 6 months since prior cervical fusion/ACDF at the same level before evaluating for revision for pseudoarthrosis

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior authorization required

Prior authorization is required when requesting anterior cervical discectomy and fusion (ACDF), repeat ACDF, or anterior cervical corpectomy with fusion; requests must demonstrate that the applicable procedure‑specific criteria are met.

Requests must demonstrate the applicable procedure‑specific criteria are met (e.g., initial ACDF, repeat ACDF, corpectomy).

Prior Authorization

Codes table and PA notice

The policy includes a codes table and states that inclusion of a code in the table does not imply the code is under management or requires prior authorization; providers must refer to the applicable health plan and the member’s Certificate of Coverage or Evidence of Coverage for management and payment details.

"The inclusion of any code in this table does not imply that the code is under management or requires prior authorization."
Prior authorization of a listed code is not a guarantee of payment; refer to the member’s Certificate of Coverage or Evidence of Coverage.

Background and Clinical Context

Background: Anterior cervical discectomy and fusion (ACDF) is used to treat symptomatic cervical radiculopathy and myelopathy caused by neural compression from disc herniation, stenosis, osteophytes, or cysts. The policy notes that ACDF and corpectomy must be accompanied by fusion when indicated because of procedure-related instability, and that patient selection requires supportive subjective symptoms and physical exam findings concordant with imaging. Most individuals with cervical radiculopathy improve with a 4–6 week course of non-operative treatment; exceptions include myelopathy or progressive neurologic deficit, which may not require a non-operative trial. The background section also enumerates procedural risks and complications (infection, dysphagia, dysphonia, hematoma, nerve or spinal cord injury, implant-related failures, adjacent segment disease, and pseudoarthrosis) to inform risk–benefit assessment.

Definitions and Key Terms

inv-43: Complete or partial corpectomy

DefinitionComplete or partial corpectomy: removal of at least one-half of the vertebral body (not for osteophyte resection alone)

IndicationsPerformed for infection, trauma, tumor, or compression at/behind the vertebral body

Surgical requirementMust be performed with cervical fusion due to iatrogenic instability caused by corpectomy

inv-44: Adjacent Segment Disease (ASD)

DefinitionAdjacent Segment Disease (ASD): degenerative spinal segment adjacent to a prior decompression or fusion causing symptoms that meet the policy's criteria

Timing requirementGreater than 6 months since the prior cervical decompression or fusion at an adjacent level

Policy Summary

Payerevicore

PolicyAnterior Cervical Discectomy and Fusion

Policy CodePolicy CMM-601

Change TypeNo material changes

Effective DateAug 4, 2026

Next Review Date

SourceLink

On This Page

Radiculopathy with Pseudoarthrosis:

>6 months since prior ACDF at the same level; symptoms: BOTH significant daily pain causing functional impairment AND unremitting radicular pain to shoulder girdle and/or upper extremity resulting in disability; physical exam: ANY of dermatomal sensory deficit, motor deficit, reflex changes, shoulder abduction relief sign, nerve root tension sign, OR unremitting radicular pain without concordant objective findings; less than clinically meaningful improvement with at least TWO conservative measures (>=6 weeks meds, >=6 weeks provider-directed exercise, and/or epidural steroid injection(s)/selective nerve root block(s)); post-operative imaging (>=6 months) shows pseudoarthrosis at requested level(s); post-operative MRI/CT shows neural compression concordant with symptoms caused by herniated disc, synovial/arachnoid cyst, central/lateral/foraminal stenosis, or osteophytes; absence of unmanaged significant mental/behavioral health disorders; nicotine-free documentation as above.

Myelopathy with Pseudoarthrosis: >6 months since prior ACDF at the same level; symptoms: ANY myelopathic features (upper/lower extremity weakness, numbness or pain, fine motor dysfunction, gait disturbance, new-onset bowel/bladder dysfunction, frequent falls); physical exam: ANY listed myelopathic signs (grip and release, ataxic gait, hyperreflexia, Hoffmann, Babinski, tandem walking ataxia, inverted brachial radial reflex, increased tone/spasticity, clonus, myelopathic hand); post-operative imaging (>=6 months after prior fusion) shows pseudoarthrosis at requested level(s); post-operative MRI/CT shows cervical spinal cord compression or stenosis concordant with symptoms; absence of unmanaged significant mental/behavioral health disorders; nicotine-free documentation as above.

Post-operative imaging to demonstrate pseudoarthrosis must be performed no less than 6 months after the prior cervical fusion

Clinical concordancePost-op MRI/CT findings must be concordant with the individual's symptoms and physical exam

inv-21: Nicotine abstinence validated by cotinine testing

Required abstinence period>= 6 weeks abstinence from smoking, smokeless tobacco, and nicotine replacement therapy prior to planned surgery validated by testing

Acceptable verification methodsObjective cotinine testing via serum, urine, or saliva verified as within the normal range for the testing method and lab

Never-smoker optionDocumentation that the individual is a never-smoker satisfies the nicotine-free requirement

inv-22: Nicotine-free validation

Definition of nicotine-free statusIndividual is a never-smoker OR has refrained from smoking, smokeless tobacco, and nicotine replacement therapy for at least 6 weeks prior to planned surgery

Objective confirmationBiochemical verification via cotinine testing (serum, urinary, or saliva) within normal laboratory range for the method used

Applies toRequired for initial ACDF, repeat ACDF with pseudoarthrosis, adjacent segment disease, and ACDF after failed arthroplasty per applicable criteria

inv-23: Post-surgical interval

Minimum interval since prior cervical surgeryGreater than 6 months since prior relevant cervical surgery (ACDF, decompression, or total disc arthroplasty) at the same or adjacent level

Context examplesApplies to repeat ACDF indications including pseudoarthrosis, radiculopathy, myelopathy, and post-arthroplasty complications

ExceptionsUrgent/emergent conditions such as progressive neurologic deficit or myelopathy may not require the non-operative interval

inv-24: Cotinine test cutoffs

Serum cutoff rangeSerum cotinine testing cutoffs reported 3.0–20 ng/mL

Saliva cutoff rangeSalivary cotinine testing cutoffs reported 10–44 ng/mL

Urine cutoffUrinary cotinine testing cutoff reported 10 ng/mL

Note

Codes listed (EIU table)

The EIU (Experimental, Investigational, or Unproven) codes table lists ACDF‑related CPT and add‑on codes (for example: 22220, 22548, 22551, +22552, 22554, +22585, +22845 and additional add‑on codes and discectomy/corpectomy codes).

Examples of listed codes: 22220; 22548; 22551; +22552; 22554; +22585; +22845; +22846; +22853; +22854; +22859; 63075; +63076; 63081; +63082.

Note

Prior authorization references

Reference sections cite clinical guidelines and literature (including NASS recommendations) that inform clinical indications and coverage rationale but do not themselves state operational prior authorization rules or code lists.

Reference examples include NASS Coverage Policy Recommendations and numbered bibliographic citations.

Step Therapy

Conservative therapy requirements

Providers must document failure or insufficient improvement after specified conservative therapies—typically at least six (6) weeks of prescription‑strength analgesics/steroids/gabapentinoids/NSAIDs and/or a six (6) week provider‑directed exercise program—before approval for many radiculopathy or related indications.

Conservative therapies listed include: prescription analgesics/steroids/gabapentinoids/NSAIDs for six (6) weeks and provider‑directed exercise for six (6) weeks.
Epidural steroid injection(s) or selective nerve root block(s) are included where specified.

Step Therapy

Conservative therapy requirement

For indications involving pseudoarthrosis, radiculopathy, or adjacent segment disease, documentation must show less than clinically meaningful improvement after specified conservative measures (e.g., at least two conservative therapies including six (6) weeks of meds and six (6) weeks of provider‑directed exercise; epidural steroid injection where applicable).

Radiculopathy with pseudoarthrosis requires failure of at least two measures: six (6) weeks meds, six (6) weeks exercise, or epidural/nerve block(s).
Adjacent segment disease radiculopathy similarly requires less than clinically meaningful improvement with at least two conservative measures.

Note

Non-operative trial guidance

Most individuals with cervical radiculopathy should undergo a 4–6 week course of non‑operative treatment prior to surgery; exceptions include myelopathy or progressive neurologic deficit where a trial may not be necessary.

Typical non‑operative trial duration cited: 4–6 weeks.
Exception: myelopathy or progressive neurologic deficit may not require a trial of non‑operative treatment.

Step Therapy

No step therapy requirements specified

No formal step therapy program is specified in the reference sections of this policy; the document does not define plan‑level step edits beyond the conservative therapy expectations in the clinical criteria.

The references do not specify additional step therapy mandates beyond the clinical conservative therapy requirements.

Documentation Required

Required documentation

Documentation submitted for authorization must include imaging concordant with symptoms (MRI/CT and plain x‑rays including flexion/extension), objective cotinine testing to confirm nicotine‑free status when required, and evidence of prior conservative treatments with durations.

Plain x‑rays including flexion/extension and MRI/CT showing neural compression concordant with symptoms are required.
Objective cotinine testing (serum, urine, or saliva) verified within the normal range for the testing method and lab when nicotine abstinence is claimed.
Evidence of prior conservative treatments and their durations (e.g., six (6) weeks) must be provided.

Documentation Required

Behavioral health and nicotine testing documentation

When nicotine‑free status is required, providers must document absence of unmanaged behavioral health disorders and provide biochemical verification of nicotine abstinence by either documenting the member as a never‑smoker or providing cotinine testing (serum, urine, or saliva) showing values within the normal range for the assay.

Behavioral health: absence of unmanaged significant mental/behavioral disorders (e.g., major depressive disorder, chronic pain syndrome, substance use disorders).
Nicotine testing: validated cotinine testing (serum, urine, or saliva) with lab‑specific normal range; cotinine cutoff ranges reported in the policy (e.g., serum 3.0–20 ng/mL; saliva 10–44 ng/mL; urine 10 ng/mL).

Documentation Required

Clinical and imaging documentation

Clinical documentation should describe presenting symptoms and functional impairment, include concordant physical exam findings, and supply post‑operative imaging (plain x‑rays including flexion/extension and MRI/CT) demonstrating pseudoarthrosis, neural compression, or other structural causes concordant with symptoms.

Specify symptom details (e.g., daily significant pain, unremitting radicular pain, or myelopathic signs).
Include objective physical exam findings listed in the criteria (dermatomal deficits, motor deficits, reflex changes, myelopathic signs).
Provide post‑operative imaging performed at no less than six (6) months when required to document pseudoarthrosis.

Billing Rule

Refer to applicable health plan for payment terms

Providers should refer to the applicable health plan and the member’s Certificate of Coverage or Evidence of Coverage for payment terms and to determine whether plan‑specific prior authorization or management applies to listed codes.

The policy states that inclusion of a code in the table does not imply it is under management; refer to the applicable health plan for management details and payment terms.

Note

Bibliographic references (no operational doc)

The references section provides bibliographic citations supporting clinical indications, outcomes, complications, and guideline sources; it does not contain operational documentation requirements or additional provider actions.

Reference list includes NASS guidelines and multiple clinical studies cited to support clinical content, not operational mandates.

Denial Risk

Potential denial triggers

Requests lacking documentation of attempted conservative therapy (for example, failure of at least six (6) weeks of prescription‑strength meds and six (6) weeks of provider‑directed exercise, or other required conservative measures) or lacking required post‑operative imaging for pseudoarthrosis are potential denial triggers.

Potential denial if conservative therapy durations (e.g., six (6) weeks) are not documented.
Potential denial if post‑operative imaging demonstrating pseudoarthrosis (performed no less than six (6) months after prior fusion) is not provided when required.

Denial Risk

Not medically necessary when criteria unmet

Procedures performed without meeting the General Guidelines and the applicable procedure‑specific criteria (e.g., initial ACDF, corpectomy with fusion, repeat ACDF, adjacent segment disease, or fusion following failed arthroplasty) are considered not medically necessary and may be denied.

Examples of not medically necessary uses include ACDF for chronic non‑specific neck or arm pain of unknown etiology or for cervical degenerative disc disease without radiculopathy or myelopathy.
ACDF or corpectomy performed without a cervical fusion is considered not medically necessary.

Note

Inclusion of a code in the table does not imply management or prior authorization

The policy explicitly notes that the inclusion of a code in the EIU codes table does not imply that the code is under management or requires prior authorization; prior authorization of a listed code is not a guarantee of payment.

"The inclusion of any code in this table does not imply that the code is under management or requires prior authorization."
Prior authorization of a code listed in this table is not a guarantee of payment.

Note

References section contains literature citations, not operational triggers

The references section contains literature citations (NASS and other studies) that inform clinical guidance; these citations are not operational triggers and do not add additional provider action requirements beyond the policy criteria.

References are bibliographic (numbered studies and guideline documents) supporting clinical content, not additional operational instructions.

Diagnostic requirementsImaging must show successful decompression/fusion at the previous level and neural structure compression at the requested level concordant with symptoms

inv-45: Failed Cervical Disc Arthroplasty

DefinitionFailed cervical disc arthroplasty: post-operative imaging showing implant malposition or failure (e.g., subsidence, loosening, infection, dislocation, subluxation, vertebral body fracture, dislodgement)

Related indicationsMay warrant ACDF when accompanied by concordant symptoms and fulfillment of other procedure-specific criteria (timing, conservative therapy, nicotine-free status)

Imaging requirementPost-operative MRI/CT must be concordant with the individual's symptoms and physical exam findings

inv-46: Contraindications

Contraindicated indicationsACDF is contraindicated for treatment of discogenic axial neck pain and for isolated cervical radiculopathy due to foraminal stenosis amenable to simple foraminotomy (per NASS)

Behavioral health considerationAbsence of unmanaged significant mental/behavioral health disorders is required for surgical candidacy

Non-operative trial exceptionIndividuals with myelopathy or progressive neurologic deficit may not require a trial of non-operative treatment

inv-47: Cotinine testing cutoffs

Serum cutoffs3.0–20 ng/mL (reported range)

Saliva cutoffs10–44 ng/mL (reported range)

Urine cutoff10 ng/mL

inv-48: NASS guidelines

Source guidanceNorth American Spine Society (NASS) Coverage Policy Recommendations: Cervical Fusion cited as a referenced guideline

Non-operative recommendationNASS recommends a trial of non-operative management (4–6 weeks) for cervical radiculopathy before surgery when appropriate

Contraindication noteNASS lists ACDF as contraindicated for discogenic axial neck pain and isolated foraminal stenosis amenable to foraminotomy