CurrentevicorePolicy CMM-602

Cervical Total Disc Arthroplasty

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This policy governs medical necessity criteria, general guidelines, and indications for cervical total disc arthroplasty (CTDA) for Cigna-administered health benefit plans and describes review pathways for initial, failed, and adjacent-segment scenarios.

Policy Summary

Payerevicore

PolicyCervical Total Disc Arthroplasty

Policy CodePolicy CMM-602

Change TypeNo material change

Effective DateAug 4, 2026

Next Review Date

Key ActionObtain prior authorization per CMM-600.1 and document age ≥18, DEXA T-score > -1.5 for at-risk individuals, nicotine-free status via cotinine testing, concordant imaging, and failed nonoperative management when required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥18minimum patient age for indication

single- or contiguous 2-levelallowed implant reconstruction levels

T-score > -1.5DEXA requirement (at-risk)

≥6 weeksnicotine abstinence

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CurrentevicorePolicy CMM-602

Cervical Total Disc Arthroplasty

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Policy Summary

Payerevicore

PolicyCervical Total Disc Arthroplasty

Policy CodePolicy CMM-602

Change TypeNo material change

Effective DateAug 4, 2026

Next Review Date

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥18minimum patient age for indication

single- or contiguous 2-levelallowed implant reconstruction levels

T-score > -1.5DEXA requirement (at-risk)

≥6 weeksnicotine abstinence

adjacent segment planned scope

Coverage Criteria for Cervical Total Disc Arthroplasty

Initial Primary Cervical Total Disc Arthroplasty — Radiculopathy or Myelopathy

Initial primary cervical total disc arthroplasty is considered medically necessary when performed for EITHER radiculopathy OR myelopathy and ALL associated criteria below are met.

Indication

Common eligibility requirements: Age ≥18; absence of osteoporosis or severe osteopenia (e.g., prior DEXA T-score > -1.5 for at-risk individuals); cervical disc prosthesis is FDA-approved and used per labeling; planned reconstruction at C3–C7 following discectomy; planned implant(s) for single-level or contiguous two-level replacement(s); no previous surgeries at the operative level; documentation of nicotine-free status (see indication-specific nodes where required); absence of unmanaged significant mental/behavioral health disorders; absence of clinically significant cervical instability on plain x-rays (see instability thresholds).
Compiled from general and indication-specific criteria
Radiculopathy-specific: Symptoms: significant daily pain causing clinically significant functional impairment and 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), or unremitting radicular pain without concordant objective findings. Imaging: MRI/CT demonstrating neural structure compression at the requested level(s) concordant with symptoms caused by herniated disc (including retained or recurrent material), synovial/arachnoid cyst, central/lateral/foraminal stenosis, or osteophytes. Failed conservative management: less than clinically meaningful improvement after at least TWO of the following unless contraindicated — (1) prescription-strength analgesics/steroids/gabapentinoids/NSAIDs for 6 weeks, (2) provider-directed exercise program for 6 weeks, (3) epidural steroid injection(s) or selective nerve root block(s) at the same level(s). Exclusions: absence of clinically significant cervical instability on plain x-rays (no subluxation/translation >3.5 mm, sagittal plane angulation ≤11°, no kyphotic deformity/significant reversal of lordosis or spondylolisthesis).At least 2 failed non-operative modalities
Myelopathy-specific: Symptoms: upper or 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 test abnormality, ataxic gait, hyperreflexia, Hoffmann sign, Babinski sign, tandem walking ataxia, inverted brachioradialis reflex, increased tone/spasticity, clonus, or myelopathic hand. Imaging: MRI/CT showing cervical spinal cord compression or cervical spinal stenosis concordant with symptoms and exam. Exclusions: absence of clinically significant cervical instability on plain x-rays (no subluxation/translation >3.5 mm, sagittal plane angulation ≤11°, no kyphotic deformity/significant reversal of lordosis or spondylolisthesis).

Adjunct criteria for adjacent segment cervical TDA (radiculopathy or myelopathy)

Considered medically necessary when EITHER radiculopathy or myelopathy criteria are met and ALL associated criteria below are satisfied:

Timing and device: Prior adjacent-level cervical total disc arthroplasty was performed at least 6 months prior; planned implant is FDA-approved and used per labeling; planned implant is for a single-level adjacent segment replacement at C3–C7 following discectomy.6 months

Age and bone health: Age ≥18 years; absence of osteoporosis or severe osteopenia (e.g., prior DEXA T-score > -1.5 for at-risk individuals).DEXA T-score > -1.5

At-risk individuals include women ≥65, men >70, those with medical conditions affecting bone mineral density, individuals receiving glucocorticoids >3 months, or age ≥50 with minimal-trauma fracture.

Nicotine status: Documentation of nicotine-free status by either never-smoker OR abstinence from smoking, smokeless tobacco, and nicotine replacement therapy for ≥6 weeks prior to planned surgery validated by objective cotinine testing (serum, urine, or saliva) within the normal range for the testing method and lab.

Clinically significant cervical instability on plain x-rays excludes eligibility for cervical total disc arthroplasty. Radiographic thresholds specified in the policy are: subluxation or translation >3.5 mm on static lateral or dynamic flexion/extension views; sagittal plane angulation >11° between adjacent spinal segments on static or dynamic flexion/extension lateral views; and the presence of a kyphotic deformity, significant reversal of lordosis, or spondylolisthesis. These instability findings apply to both radiculopathy- and myelopathy-specific indications and must be absent on plain x-rays for the procedure to meet criteria.

Cervical total disc arthroplasty is considered not medically necessary when performed for degenerative disc disease as the sole indication. The policy also states that CTDA following a failed cervical total disc arthroplasty at the same level is considered not medically necessary. These scenarios are explicitly listed under the Not Medically Necessary section and therefore do not meet coverage criteria.

The referenced pages in this segment are bibliographic and evidence-focused; within these extracted reference pages there are no additional explicit coverage exclusions beyond those stated in the policy's Not Medically Necessary and Exclusions sections. The references support the evidence base but do not themselves define new coverage exclusions.

The policy notes the existence of a Non-Indications (Non‑Indications) section identified as CMM‑602.5. Specific non‑indications or 'not medically necessary' conditions are detailed in that section; reviewers should refer to CMM‑602.5 for the full list and for any referral or cross‑reference instructions.

Revision of a failed cervical total disc arthroplasty at the same level is listed as a not medically necessary indication. The policy further enumerates multiple contraindications and non‑covered scenarios (for example, allergy to implant materials, active systemic infection, metabolic bone disease, severe spondylosis with bridging osteophytes or >50% disc collapse, severe facet arthropathy, OPLL) that, when present, make CTDA contraindicated and not eligible for coverage.

Within the extracted chunks provided, there are no standalone determinations labeled only as 'not medically necessary' beyond the Not Medically Necessary section already cited. The policy text calls out specific not medically necessary scenarios (e.g., CTDA for degenerative disc disease alone, revision at same level) and lists contraindications; the reference material itself is bibliographic and does not introduce additional NMN determinations.

Procedure and Test Coding

Procedure CodesCPT

22856	Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation, single interspace, cervical
+22858	Total disc arthroplasty, second level (add-on)
22861	Revision including replacement of total disc arthroplasty, anterior approach, single interspace; cervical
22864	Removal of total disc arthroplasty, anterior approach, single interspace; cervical
+0095T	Removal of total disc arthroplasty, each additional interspace (add-on)
+0098T	Revision including replacement of total disc arthroplasty, each additional interspace (add-on)

Bone density (DEXA) T-score threshold reference (> -1.5)

DEXA T-score requirement> -1.5 (i.e., better than -1.5) on prior dual energy x-ray absorptiometry for at-risk individuals

ApplicabilityRequired for at-risk individuals undergoing CTDA (initial or adjacent-segment) as documented in preoperative testing

Measurement methodDual energy x-ray absorptiometry (DEXA) scan report

Nicotine abstinence duration requirement (cotinine validated ≥6 weeks)

Required nicotine abstinence durationRefrained from smoking, smokeless tobacco, and nicotine replacement therapy for at least 6 weeks prior to planned surgery

Validation methodObjective cotinine testing (serum, urine, or saliva) verified within the normal range for the testing method and lab

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior authorization required — see CMM-600.1

Prior authorization requirements apply for cervical total disc arthroplasty; see CMM-600.1 for timing and documentation specifics that may affect coverage determinations.

Billing Rule

Code listing and PA note — codes do not guarantee payment

The policy lists CPT procedure codes for cervical total disc arthroplasty, revisions, and removals; inclusion of these codes does not imply management, prior authorization, or guarantee payment — refer to the applicable health plan and member Certificate of Coverage.

Listed codes: 22856, +22858, 22861, 22864, +0095T, +0098T

Background

Cervical total disc arthroplasty (CTDA) is presented as a surgical option for individuals with symptomatic cervical radiculopathy or myelopathy when conservative management has failed or in urgent/emergent situations. Indications require concordant clinical findings and imaging, patient age of ≥18 years, appropriate bone health and device labeling adherence, and absence of clinically significant cervical instability. For radiculopathy, documentation of less than clinically meaningful improvement after at least two non‑operative modalities (examples include 6 weeks of prescription analgesics/steroids/gabapentinoids/NSAIDs, 6 weeks of provider‑directed exercise, or epidural steroid/selective nerve root injection) is required unless contraindicated.

Definitions and Key Terms

Urgent/emergent indications (central cord syndrome, cord signal change on MRI, progressive neurologic deficit)

Included conditionsCentral cord syndrome

Cord/cord signal changeMyelopathy or cord signal changes on MRI due to cord compression

Progressive neurologic deficitProgressive neurological deficit documented on two separate physical exams

Severe neurologic signsMotor weakness ≤ grade 3/5, rapidly progressive motor loss, or bowel/bladder incontinence/retention

Single-level adjacent segment replacement following discectomy with planned implant at C3-C7

Planned implant scopeSingle-level adjacent segment replacement following discectomy with planned implant at C3–C7

Revision History

2026-08-04policy_effective_dateLatest

Guideline CMM-602: Cervical Total Disc Arthroplasty published with an effective date of 2026-08-04.

2018-01-01bibliographic_update

Systematic review and meta-analysis on treatment of cervical adjacent segment disease (Lu et al.) referenced in the guideline bibliography.

Policy Summary

Payerevicore

PolicyCervical Total Disc Arthroplasty

Policy CodePolicy CMM-602

Change TypeNo material change

Effective DateAug 4, 2026

Next Review Date

SourceLink

On This Page

≥6 weeks abstinence

Cotinine cutoffs vary by method.

Operative history: No previous surgeries at the operative level.

Radiculopathy-specific clinical requirements: Symptoms: significant daily pain causing clinically significant functional impairment and unremitting radicular pain to the 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 (e.g., Spurling), or unremitting radicular pain without concordant exam findings. Imaging: MRI/CT showing neural structure compression at the requested level(s) concordant with symptoms caused by herniated disc, synovial/arachnoid cyst, central/lateral/foraminal stenosis, or osteophytes. Failed conservative management: less than clinically meaningful improvement after at least TWO non-operative modalities (prescription-strength analgesics/steroids/gabapentinoids/NSAIDs for 6 weeks; provider-directed exercise for 6 weeks; epidural steroid/selective nerve root injection) unless contraindicated. Imaging: flexion/extension lateral views must demonstrate successful CTDA at the adjacent level. Absence of clinically significant cervical instability on plain x-rays (no subluxation/translation >3.5 mm, sagittal plane angulation ≤11°, no kyphotic deformity/reversal of lordosis or spondylolisthesis).At least 2 failed non-operative modalities

Myelopathy-specific clinical requirements: Symptoms: upper or lower extremity weakness, numbness, or pain; fine motor dysfunction; gait disturbance; new-onset bowel/bladder dysfunction; or frequent falls. Physical exam: ANY of grip-and-release abnormality, ataxic gait, hyperreflexia, Hoffmann sign, Babinski sign, tandem walking ataxia, inverted brachioradialis reflex, increased tone/spasticity, clonus, or myelopathic hand. Imaging: MRI/CT showing cervical spinal cord compression or cervical spinal stenosis concordant with symptoms. Absence of clinically significant cervical instability on plain x-rays as defined above.

Alternate status acceptedIndividual documented as a never-smoker (no cotinine required)

Cotinine urinary cutoff values (urine 10 ng/mL; serum/saliva ranges noted)

Urine cotinine cutoff10 ng/mL (urinary testing)

Serum cotinine rangeReported serum cutoffs ranged from 3.0 ng/mL to 20 ng/mL (method/lab dependent)

Saliva cotinine rangeReported salivary cutoffs ranged from 10 ng/mL to 44 ng/mL (method/lab dependent)

DEXA T-score threshold for absence of osteoporosis/severe osteopenia (> -1.5)

DEXA threshold for absence of osteoporosis/severe osteopenia> -1.5 (i.e., better than -1.5) on prior DEXA for at-risk individuals

Applies toInitial primary CTDA and adjacent-segment CTDA candidates aged ≥18 who meet at-risk criteria

Source testDual energy x-ray absorptiometry (DEXA) scan report documented in medical record

Note

No additional prior authorization rules specified in this section

These reference pages do not specify additional prior authorization rules or identify specific affected billing codes beyond the general note to consult the health plan and CMM-600.1.

Note

References section — prior authorization not addressed here

The bibliographic/reference portion of the document does not provide prior authorization instructions for providers; see the policy sections and CMM-600.1 for requirements.

Documentation Required

Document failed non-surgical therapy for radiculopathy (≥2 modalities)

For radiculopathy, document less than clinically meaningful improvement after at least TWO non‑surgical treatments (unless contraindicated), such as 6 weeks of prescription analgesics/steroids/gabapentinoids/NSAIDs, 6 weeks of a provider‑directed exercise program, or epidural steroid/selective nerve root injection(s).

Document which two non-surgical modalities were tried and the duration (e.g., 6 weeks each where specified).

Documentation Required

Non‑operative management requirement — document at least two failed modalities

Documentation must show insufficient improvement after at least two non‑operative modalities (examples include 6 weeks of prescription analgesics/steroids/gabapentinoids/NSAIDs, 6 weeks of a provider‑directed exercise program, or epidural steroid/selective nerve root block) unless contraindicated.

Specify the modalities attempted, dates, and objective/subjective response to each.
Indicate if any modality was contraindicated and why.

Step Therapy

No step therapy requirements described

No formal step therapy or sequencing requirements for cervical total disc arthroplasty are described in these document chunks.

Note

No step therapy or sequencing requirements in reference material

These bibliographic/reference chunks do not specify step therapy or treatment sequencing requirements for this procedure.

Documentation Required

Document age ≥18, DEXA T‑score > −1.5 for at‑risk patients, and implant/level restrictions

Document that the patient is age ≥18, that at‑risk individuals do not have osteoporosis/severe osteopenia (DEXA T‑score better than −1.5), and that the planned implant is for single‑level or contiguous two‑level reconstruction at C3–C7 following discectomy; also document no prior surgery at the operative level.

For at‑risk individuals (eg, women ≥65, men >70, chronic glucocorticoid use), include DEXA result showing T‑score > −1.5.
Confirm planned implant FDA approval and use per labeling; state planned levels (C3–C7) and whether single‑level or contiguous two‑level.

Documentation Required

Preoperative nicotine testing — objective cotinine verification (≥6 weeks abstinence)

Obtain objective nicotine‑free status prior to planned surgery: document either never‑smoker status or at least six (6) weeks of abstinence validated by cotinine testing (serum, urine, or saliva) with results within the normal range for the testing method and laboratory.

Urine cotinine cutoff noted as 10 ng/mL; serum and saliva cutoffs vary by method.
Record test type, date, numeric result, and lab reference range.

Note

No additional documentation requirements specified in these reference pages

The extracted reference pages in this portion of the document do not specify additional documentation requirements beyond those in the criteria sections.

Note

References do not specify documentation requirements

These bibliographic chunks do not include procedure‑specific documentation requirements; rely on the policy criteria and CMM‑600.1 for required documentation.

Denial Risk

Denial risk: noncompliance with CMM‑600.1 prior authorization

Failure to follow prior authorization requirements described in CMM‑600.1 may affect medical necessity determinations and could result in denial of coverage.

Denial Risk

Denial risk: failure to meet guidelines or presence of contraindications

Procedures that do not meet the General Guidelines or procedure‑specific criteria, or that are performed when listed contraindications are present, are considered not medically necessary and may be denied.

Examples of contraindications: active systemic infection; osteoporosis/osteomalacia; severe spondylosis with bridging osteophytes; severe facet arthropathy; OPLL; allergy to implant materials.

Note

References section — no explicit authorization/denial requirements

The reference section contains citations and bibliographic material only and does not provide explicit authorization or denial instructions for providers.

Note

Literature citations only — no authorization/denial trigger language

These bibliographic chunks contain literature citations only and do not define authorization or denial triggers.

Timing since prior adjacent C-TDAPrior adjacent-level cervical TDA performed at least 6 months prior

Age requirementPatient age ≥18 years

At-risk individuals for osteoporosis definition (age/gender thresholds, chronic glucocorticoid therapy, prior fragility fractures)

Age/gender thresholdsAt-risk includes women age ≥65 years and men age >70 years

Glucocorticoid exposureIndividuals receiving (or expected to receive) glucocorticoid therapy for >3 months

Prior fragility fracturesIndividuals aged ≥50 with minimal-trauma wrist, hip, spine, or proximal humerus fracture

Other conditionsMedical conditions that could alter bone mineral density (per clinical judgment)

Cervical total disc arthroplasty definition

DefinitionSurgical implantation of an artificial cervical disc device to replace a diseased intervertebral disc and preserve motion (also called cervical artificial disc replacement)

Typical indicationUsed to treat symptomatic degenerative disc disease causing radiculopathy or myelopathy when criteria are met

Anatomic scopeImplants are used for reconstruction at C3–C7 following discectomy

FDA SSED (Summary of Safety and Effectiveness Data) — definition/reference

DefinitionFDA Summary of Safety and Effectiveness Data (SSED) are regulatory documents summarizing safety and effectiveness data for specific implanted cervical disc devices (e.g., ProDisc-C, Prestige LP, M6-C)

Use in policySSEDs are cited as device-specific regulatory evidence to support implant safety/effectiveness

AccessAvailable from the U.S. Food & Drug Administration website (device-specific PMA/SSED documents)

NASS guidance — definition/reference

DefinitionNorth American Spine Society (NASS) guidance refers to coverage policy recommendations and evidence-based clinical guidelines relevant to cervical artificial disc replacement and cervical radiculopathy

Examples citedNASS Coverage Policy Recommendations: Cervical Artificial Disc Replacement (Feb 2024) and NASS Evidence-Based Clinical Guidelines for Cervical Radiculopathy (2010)

Role in policyNASS guidance is referenced as an external evidence and guideline source informing policy decisions