Lumbar Total Disc Arthroplasty
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Defines medical necessity, non-indications, coding, and prior authorization guidance for lumbar total disc arthroplasty for providers and medical directors for Cigna-administered plans.
No material clinical or coverage changes in this revision.
Coverage Criteria for Lumbar Total Disc Arthroplasty
Initial Primary Lumbar Total Disc Arthroplasty
Initial primary lumbar total disc arthroplasty is considered medically necessary when ALL of the following criteria have been met:
Medical necessity criteria
Covered when ALL of the following are met
Reference: 2024 NASS Coverage Policy Recommendations
Lumbar total disc arthroplasty (TDA) is not indicated when performed using partial-disc prosthetics, as an adjunctive treatment for primary central or far‑lateral disc herniation, or for revision of a previously failed lumbar artificial total disc arthroplasty. These scenarios are explicitly identified as outside the scope of covered initial primary lumbar TDA and are considered not medically necessary under this policy.
Procedures performed without meeting the General Guidelines and the procedure‑specific criteria for initial lumbar disc arthroplasty are considered not medically necessary and may be denied. This includes any request for TDA that does not satisfy the documented criteria for patient selection, imaging confirmation, or required conservative management.
The 2024 NASS guidance and the policy identify multiple contraindications to lumbar TDA. Key conditions include spinal instability or spondylolisthesis greater than Grade I, chronic radiculopathy, osteopenia or osteoporosis, significant facet arthropathy at the operative level, active infection or tumor at the implantation site, and age outside the range of 18–60 years. These contraindications also encompass poorly managed psychiatric disorders and other structural pathologies that would compromise implant outcomes.
The reference list for this policy presents supporting literature and device data but does not by itself state additional explicit coverage exclusions beyond those enumerated in the policy body. References are provided for clinical context and evidence review.
When any listed contraindication is present the procedure is considered not medically necessary. Specific measurable thresholds cited in the policy include an osteopenia/osteoporosis cutoff of T‑score < -1.0 and imaging findings such as degenerative or lytic spondylolisthesis > 3 mm, which would justify denial of coverage.
Lumbar TDA is intended only for patients who have completed an adequate course of conservative care and who do not have unmanaged behavioral health conditions. Requests for TDA may be denied when the patient has not documented a failure of at least 6 months of structured non‑operative management, or when significant mental or behavioral health disorders remain unmanaged and could adversely affect surgical outcomes.
The bibliographic/reference section of this policy compiles cited studies and device summaries but does not itself contain additional statements declaring services not medically necessary; all exclusionary and denial criteria are specified in the policy sections referenced above.
Coding and Key Clinical Thresholds
| 22857 | Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar |
| 22860 | Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace; second interspace, lumbar (List separately in addition to code for primary) |
| 22862 | Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar |
| 22865 | Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar |
| +0164T | Removal of total disc arthroplasty, (artificial disc), anterior approach, each additional interspace, lumbar (List separately in addition to code for primary procedure) |
| +0165T | Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, lumbar (List separately in addition to code for primary procedure) |
Prior Authorization, Documentation, and Denial Risk
Prior authorization governed by CMM-600.1; affected CPT codes listed
Prior authorization timing and documentation requirements are governed by CMM-600.1. Codes related to lumbar total disc arthroplasty and revisions/removals that are referenced in this policy include CPT 22857, 22860, 22862, 22865 and CPT add-on codes +0164T and +0165T; inclusion in the code table does not itself imply management or guarantee payment—refer to the applicable health plan and CMM-600.1 for authorization details.
Prior authorization must confirm indication, contraindication assessment, and failed conservative management
Prior authorization must confirm the indication is discogenic low back pain at L3‑L4, L4‑L5, or L5‑S1, documented single‑level disease on imaging, assessment for listed contraindications and unmanaged mental/behavioral health, and evidence of failure of at least six (6) months of structured non‑surgical medical management.
- Confirm operative levels are L3‑L4, L4‑L5, or L5‑S1 and imaging shows single‑level moderate to severe degeneration
- Assess for contraindications per NASS and unmanaged psychiatric/behavioral health disorders
- Document failure of ≥6 months of non‑surgical medical management
FDA device SSEDs (ProDisc‑L, Charité) are cited
The policy cites FDA Summaries of Safety and Effectiveness Data (SSEDs) for device evidence: ProDisc‑L (PMA P050010) and Charité (PMA P040006); these SSEDs are referenced in the bibliography and may be used as device evidence during review.
- FDA SSED PMA P050010 — ProDisc‑L
- FDA SSED PMA P040006 — Charité
Documented failure of structured physician‑supervised nonoperative care required
Prior authorization must include documentation of structured physician‑supervised, multi‑modal nonoperative care showing regularly scheduled appointments, follow‑up evaluation, and less than clinically meaningful improvement with both prescription‑strength analgesics/steroids/gabapentinoids/NSAIDs and a provider‑directed exercise program.
- Nonoperative care must be physician‑supervised and multi‑modal
- Include records of regularly scheduled visits and follow‑up evaluations
- Document inadequate improvement despite BOTH medication management and a provider‑directed exercise program
Documented ≥6‑month trial of conservative (non‑surgical) therapy required
A documented trial of non‑surgical medical management for at least six (6) consecutive months is required before consideration of lumbar total disc arthroplasty.
- Conservative therapy must last ≥ 6 months
- Includes prescription‑strength medications and provider‑directed exercise program
No step therapy requirements specified in references
No step therapy programs or stepwise authorization requirements are specified in the policy’s reference section.
- Reference list section does not include step therapy requirements
Authorization and documentation must follow CMM‑600.1 and include imaging confirmation
Prior authorization and required documentation must follow CMM‑600.1 and include imaging that confirms single‑level moderate to severe disc degeneration at the operative level and absence of exclusionary findings.
- Include plain x‑rays and advanced imaging (CT or MRI) confirming single‑level moderate to severe degeneration
- Demonstrate absence of degenerative disease above L3‑L4 and absence of multi‑level disease
Required documentation: levels, ≥6 months conservative care, and absence of contraindications
Documentation submitted for authorization should explicitly demonstrate discogenic low back pain at L3‑L4, L4‑L5, or L5‑S1, failure of at least six (6) months of conservative care, and absence of contraindications (including unmanaged psychiatric/behavioral health disorders) referenced in the policy.
- State operative level(s): L3‑L4, L4‑L5, or L5‑S1
- Provide evidence of ≥6 months of failed conservative care
- Confirm no unmanaged mental/behavioral health disorders and no listed contraindications
Bibliography provides references but does not add documentation requirements
The bibliographic/reference section lists device studies and FDA SSEDs but does not itself impose additional operational documentation requirements for authorization.
- References are citation‑only and do not specify extra documentation steps
Denial risk if criteria not met or contraindications present
Requests for lumbar total disc arthroplasty that do not meet the General Guidelines and the procedure‑specific criteria, or that are performed when any listed contraindication is present, are considered not medically necessary and may be denied.
- Procedures without meeting criteria in General Guidelines and procedure‑specific section are not medically necessary
- Presence of any listed contraindication (e.g., osteopenia/osteoporosis, preop remaining disc height <3 mm) makes the procedure not medically necessary
Denial triggers: missing ≥6‑month conservative trial, unmanaged behavioral health, contraindications
Common denial triggers include failure to document ≥6 months of non‑surgical medical management, presence of unmanaged mental or behavioral health disorders, or presence of listed contraindications (e.g., spondylolisthesis > Grade I, significant facet arthropathy, age <18 or >60, infection, tumor).
- No documented failure of ≥6 months conservative care
- Unmanaged psychiatric or behavioral health disorders
- Any listed contraindication (spinal instability/spondylolisthesis > Grade I; significant facet arthropathy; age outside 18–60; infection; tumor)
Reference list does not contain separate authorization/denial criteria
The policy’s reference list provides studies and FDA SSED citations but does not itself include separate authorization or denial criteria—operational requirements are in the main criteria and CMM‑600.1.
- Reference list is bibliographic and does not state authorization/denial rules
Background
Lumbar total disc arthroplasty is a single‑level anterior approach procedure intended to treat symptomatic degenerative disc disease at L3‑4, L4‑5, or L5‑S1 in carefully selected patients. The operation replaces the diseased disc with an artificial disc to address axial discogenic low back pain (± radicular symptoms) after failure of non‑surgical management, with selection emphasizing appropriate age, imaging‑confirmed single‑level degeneration, absence of severe facet or other contraindicating pathology, and completion of structured multi‑modal conservative therapy.
Definitions
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