Artificial Intervertebral Disc
Customize your policy alerts
Sign up for Geisinger Health Plan Policy MP147 alerts
Get alerted when Policy MP147 changes without checking for updates manually.
Monitor payer policy activity
Defines Geisinger Health Plan coverage stance, prior authorization requirements, coding, and medical necessity considerations for artificial intervertebral disc (total disc arthroplasty) procedures across applicable lines of business.
No material clinical or coverage changes in this revision.
Coverage Determinations and Medical Necessity
General coverage conditions
Covered when ALL of the following are met:
See Definitions for full medical necessity criteria.
For PA Medicaid business segment, this policy applies as written.
Cohere uses proprietary clinical criteria and utilization management tools; consult Cohere and member benefit document for authorization requirements.
Refer to MP015 for additional information on experimental, investigational or unproven services.
Coverage for experimental or investigational treatments, services and procedures is expressly excluded under the member's certificate with Geisinger Health Plan. This exclusion also applies to unproven services provided outside of an approved clinical trial. Refer to policy MP015 Experimental, Investigational or Unproven Services for additional details.
Services that are determined to be experimental, investigational, or unproven when not performed within an approved clinical trial are considered not medically necessary and are excluded from coverage under the member's certificate with Geisinger Health Plan.
Prior Authorization and Provider Requirements
Obtain prior authorization through Cohere
Prior authorization is required through Cohere for applicable lines of business; coverage is subject to member-specific benefit documents and applicable Medicare LCD/NCD rules. Providers must obtain prior authorization via Cohere before scheduling these services for members in the specified lines of business.
- Applies to Commercial HMO/PPO, Medicare Advantage, GHP Family Medicaid and CHIP products as indicated through Cohere.
- For Medicare members, applicable LCDs and NCDs supersede this policy — confirm Medicare-specific rules.
- Consult member-specific benefit document for eligibility and contract-specific limitations.
Submit case-by-case review requests for Medicaid
For the Medicaid business segment, requests that do not meet the PARP criteria may be evaluated on a case-by-case basis. Submit a full case presentation through the Cohere process for consideration under Medicaid.
- Indicate Medicaid product (GHP Family Medicaid/PA Medicaid) on the request.
- Include all supporting clinical documentation to support a case-by-case review.
Confirm prior authorization and member eligibility
Prior authorization and eligibility determinations must be confirmed via Cohere and by reviewing the member’s contract-specific benefit document; eligibility/contract specific benefit limitations and exclusions will supersede this policy.
- Check member-specific benefit document for pre-certification lists and coverage statements.
- For Medicare members, confirm applicable LCDs/NCDs as they supersede this policy.
Do not request authorization for experimental or investigational services
Coverage for experimental, investigational, or unproven services outside an approved clinical trial is specifically excluded under the member’s certificate; submitting requests for such services risks denial. Ensure documentation demonstrates the service is not investigational and is medically necessary per the member’s benefit before requesting authorization.
- Do not request authorization for services that are excluded as experimental/investigational per the member certificate — these are not covered.
- If pursuing approval, provide evidence that the device/procedure is within approved indications and not investigational; reference MP015 where applicable.
- Prior authorization does not expand coverage for services specifically excluded in the member’s certificate.
Associated Procedure and Billing Codes
| 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); single interspace, cervical |
| 22857 | Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar |
| 22864 | Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical |
| 22865 | Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar |
Clinical Background
Artificial intervertebral discs (total disc replacements) are proposed as implants to replace the functions of the nucleus and annulus for patients with degenerative disc disease who have failed conservative therapies. Various device designs are under clinical evaluation, and because effectiveness varies by device and indication, the policy excludes use that is experimental, investigational, or unproven outside of approved clinical trials. Prior authorization or pre-certification requirements may apply; consult member-specific benefit documents and the payer’s authorization resources for applicable requirements.
Definitions and Policy Management Terms
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.