Currentsierra health and lifePolicy 2026T0437PP

Total Artificial Disc Replacement for the Spine

Defines UnitedHealthcare Commercial and Individual Exchange medical policy coverage criteria for cervical and lumbar total artificial disc replacement (TADR/TDR), including indications, contraindications (unproven uses), requirements for FDA-approved devices, and reference to InterQual clinical criteria and documentation requirements. Also includes applicable CPT/HCPCS codes and definitions.

Policy Summary

Payersierra health and life

PolicyTotal Artificial Disc Replacement for the Spine

Policy CodePolicy 2026T0437PP

Change TypeRevised criteria; definitions added; evidence updated

Effective DateFeb 1, 2026

Next Review Date

Key ActionEnsure InterQual clinical criteria are met and submit documentation of prior conservative treatments, device FDA approval, surgical technique and levels, and for lumbar cases include psychosocial-behavioral evaluation as required.

POLICY UPDATE CHANGES

Revised coverage rationale and expanded cervical and lumbar criteria, including specific proven/medically necessary statements and InterQual linkage.

Added definitions for Contiguous Levels, Hybrid Cervical Surgery, Hybrid Lumbar Surgery, and Radiographically Confirmed Complete Arthrodesis; updated 'Skeletally Mature' definition.

Updated Clinical Evidence and References sections to reflect current information and archived prior policy version 2026T0437OO.

2Max Cervical Levels Covered

1Max Lumbar Levels Covered

Unproven Uses Listed

insufficientEvidence for two-level lumbar TDR

Coverage Summary

This policy defines UnitedHealthcare Commercial and Individual Exchange coverage criteria for cervical and lumbar total artificial disc replacement (TADR/TDR). It states a mixed coverage stance: select cervical and lumbar procedures are proven and medically necessary when specific conditions are met and the referenced InterQual clinical criteria are satisfied, while certain uses are considered unproven/not medically necessary.

Key allowable levels and conditions: cervical TADR is covered for one or two contiguous levels (C3–C7), with two-level procedures requiring a device FDA‑approved for two levels and special provisions when a prior cervical fusion or prior TADR exists; lumbar TDR coverage is restricted to a single level for symptomatic intractable discogenic low back pain. The policy requires use of an FDA‑approved prosthetic intervertebral disc and fulfillment of InterQual criteria for medical necessity.

Selected policy statistics: Max Cervical Levels Covered: 2; Max Lumbar Levels Covered: 1; Unproven Uses Listed: 3 (examples include hybrid cervical surgery, hybrid lumbar surgery, and multilevel lumbar TDR).

Key Operational Stats

Max Cervical Levels Covered2

Max Lumbar Levels Covered1

Unproven Uses Listed3

Evidence for two-level lumbar TDRinsufficient

Years of minimum nonsurgical management required for RCT inclusion in trials2

Medical Necessity Criteria

Cervical Total Artificial Disc Replacement - Medically Necessary

Cervical total artificial disc replacement (TADR) is proven and medically necessary when ALL of the following are present AND InterQual criteria are met:

An FDA-approved prosthetic intervertebral disc is utilized

Individual diagnosed with only one or two Contiguous Levels of cervical degenerative disc disease (C3-C7)

Skeletally Mature individual with radiculopathy and/or myelopathy

The arthroplasty will be performed at all symptomatic Contiguous Levels (up to two levels between C3-C7)

For two-level contiguous procedures the device must be FDA-approved for two levels; when a prior cervical TADR was previously performed, the second contiguous level artificial disc must be FDA-approved for two levels.

Coding

Applicable CPT / Procedure CodesCPT

0098T	Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (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).
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.
22858	Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); second level, cervical (List separately in addition to code for primary procedure).
22860	Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression); second interspace, lumbar (List separately in addition to code for primary procedure).
22861	Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical.
22862	Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar.
22899	Unlisted procedure, spine

Provider Actions & Prior Authorization

Documentation Required

InterQual Criteria and Documentation Required

InterQual clinical criteria must be met for medical necessity determinations. For coverage of cervical and lumbar total artificial disc replacement, the InterQual CP references (Procedures, Artificial Disc Replacement, Cervical and Procedures, Artificial Disc Replacement, Lumbar) are required as part of the documentation submitted for review.

Prior Authorization

Prior Authorization Required

Prior authorization is required. Requests must demonstrate that InterQual criteria are met and include supporting documentation of prior treatments tried and failed (with dates and duration), surgical technique planned, number and location of treated levels, and, when applicable, documentation of spinal instability. For lumbar cases, a psychosocial/behavioral evaluation must also be included when indicated by InterQual.

Treatments tried/failed with dates and duration

Background & Clinical Evidence

Artificial disc replacement replaces degenerated intervertebral discs to preserve range of motion and reduce pain; prostheses are intended to improve flexibility, maintain spinal alignment, and provide an equalized weightbearing surface while reducing pain.

The policy cross‑references InterQual clinical criteria for detailed medical necessity determinations for both cervical and lumbar procedures and requires documentation of FDA device approval, prior conservative treatments, and surgical plans.

Evidence summaries indicate that single‑level cervical and lumbar TDR/TADR may provide outcomes comparable to fusion in selected patients and that randomized trials and systematic reviews support single‑level lumbar TDR in properly selected individuals. However, evidence for hybrid procedures and multilevel lumbar TDR is limited or uncertain: systematic reviews, evolving evidence reviews, and cohort studies report mixed or minimal support for hybrid lumbar constructs and insufficient evidence to establish efficacy of two‑level lumbar TDR, warranting cautious or non‑coverage designations for those uses.

Evidence source	Summary
Systematic reviews / analyses referenced
Multiple reviews (ECRI, Hayes, various systematic reviews and cohort studies) show single-level lumbar and cervical TDR may be comparable to fusion in selected patients; limited evidence for hybrid and multilevel lumbar/cervical procedures.
Hayes 2022 comparative effectiveness review
Moderate-quality evidence that 1-level LTDR is comparable with fusion; insufficient evidence for two-level LTDR and other comparisons.
Radcliff et al. 2021 IDE RCT 7-year outcomes
activL and ProDisc-L showed maintained improvements in ODI, VAS, and low reoperation rates through 7 years.
Multiple meta-analyses (2016-2021)
Several analyses found TDR superior or comparable to fusion on ODI, VAS, satisfaction, and some complication/reoperation metrics; longer-term durability mixed.

Definitions

Term	Definition
Contiguous Levels
Vertebral segments adjacent to each other (Tanasansomboon, 2023).
Hybrid Cervical Surgery
The combination of anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA) (Tanasansomboon, 2023).
Hybrid Lumbar Surgery
The combination of a total disc arthroplasty (TDA) and anterior lumbar interbody fusion (ALIF) (Scott-Young, 2018).
Radiographically Confirmed Complete Arthrodesis
Presence of trabecular bone across intervertebral space, absence of lucency between graft and endplate, absence of hardware loosening and < 1 mm of motion between spinous processes on flexion-extension radiographs (Oshina, 2018).
Skeletally Mature
Classification when endochondral ossification ceases and the physis closes by becoming totally ossified (Reith, 2018).
Contiguous Levels
Added definition in policy (exact text not shown in this part).
Hybrid Cervical Surgery
Added definition in policy (exact text not shown in this part); noted that cervical hybrid surgery performed during same plan with one-level TADR plus fusion is considered unproven/not medically necessary.
Hybrid Lumbar Surgery
Added definition in policy (exact text not shown in this part).
Radiographically Confirmed Complete Arthrodesis
Added definition in policy (exact text not shown in this part).
Skeletally Mature
Definition updated in policy (exact text not shown in this part).

Revision History

02/01/2026revisedLatest

Revised coverage rationale and expanded cervical and lumbar criteria, including specific proven/medically necessary statements and InterQual linkage. Cervical criteria clarified for one- and two-level contiguous disease, inclusion of prior fusion scenarios with requirement for radiographic complete arthrodesis, and lumbar criteria restricted to single-level disease; documentation requirements revised to include duration of conservative treatments, surgical technique, number/locations of levels, and psychosocial-behavioral evaluation for lumbar surgery.

added

Added definitions for Contiguous Levels, Hybrid Cervical Surgery, Hybrid Lumbar Surgery, and Radiographically Confirmed Complete Arthrodesis; updated 'Skeletally Mature' definition.

Policy Summary

Payersierra health and life

PolicyTotal Artificial Disc Replacement for the Spine

Policy CodePolicy 2026T0437PP

Change TypeRevised criteria; definitions added; evidence updated

Effective DateFeb 1, 2026

Next Review Date

On This Page

Cervical TADR - Medically Necessary with Prior Cervical Fusion

Cervical total artificial disc replacement in an individual with a history of prior cervical spinal fusion is proven and medically necessary when ALL of the following are present AND InterQual criteria are met:

An FDA-approved prosthetic intervertebral disc is utilized

Treating individuals with only one level or two Contiguous Levels of cervical degenerative disc disease (C3-C7)

Skeletally Mature individual with radiculopathy and/or myelopathy

The arthroplasty will be performed at all symptomatic Contiguous Levels (up to two levels between C3-C7)

Radiographically Confirmed Complete Arthrodesis of a previous cervical spinal fusion at another level (adjacent or non-adjacent)

Refer to Definitions for radiographic criteria (bridging trabecular bone, absence of lucency/hardware loosening, <1 mm motion on flexion-extension radiographs).

InterQual linkage: InterQual CP: Procedures, Artificial Disc Replacement, Cervical must be met for medical necessity

Cervical Artificial Disc Removal or Replacement

Proven and medically necessary when ALL of the following are present:

Individual has implant failure after prior disc replacement

Replacement uses an FDA-approved (one or two-level) prosthetic intervertebral disc

Cervical TADR - Not Medically Necessary / Unproven

Cervical total artificial disc replacement is unproven and not medically necessary when ANY of the following apply:

Performed at one level combined with cervical spinal fusion surgery at another level (adjacent or non-adjacent) as part of the same surgical plan (Hybrid Cervical Surgery)

Hybrid Cervical Surgery is defined as combination of ACDF and cervical disc arthroplasty.

Lumbar Total Artificial Disc Replacement - Medically Necessary

Lumbar total artificial disc replacement is proven and medically necessary when ALL of the following are present AND InterQual Client Defined criteria are met:

An FDA-approved prosthetic intervertebral disc is utilized

Treating individuals with only single level of lumbar degenerative disc disease

Maximum one lumbar level covered

Skeletally Mature individual

Symptomatic intractable discogenic low back pain attributable to that level

InterQual linkage: InterQual Client Defined CP: Procedures, Artificial Disc Replacement, Lumbar (Custom) - UHG must be met for medical necessity

Lumbar TADR - Not Medically Necessary / Unproven

Lumbar total artificial disc replacement is unproven and not medically necessary due to insufficient evidence when ANY of the following apply:

Performed at one level combined with an existing lumbar spinal fusion surgery at another level (adjacent or nonadjacent)

Performed with lumbar spinal fusion surgery as part of the same surgical plan (Hybrid Lumbar Surgery)

Hybrid Lumbar Surgery defined in Definitions

Performed at more than one spinal level

Evidence for multilevel and two-level LTDR is insufficient

Cervical Total Artificial Disc Replacement (TADR) - Proven and Medically Necessary

Covered when ALL of the following are present and InterQual criteria are met:

An FDA-approved prosthetic intervertebral disc is utilized.

Individual diagnosed with only one or two contiguous levels of cervical degenerative disc disease (C3-C7).

Skeletally mature individual with radiculopathy and/or myelopathy.

The arthroplasty will be performed at all symptomatic contiguous levels (up to two levels between C3-C7).

Cervical TADR - Two-level contiguous cases

Additional requirement for two-level contiguous cervical TADR:

The device being utilized must be FDA-approved for two levels.

When a cervical TADR was previously performed, the second contiguous level artificial disc must be FDA approved for two levels.

Cervical TADR after prior cervical fusion

Covered when ALL of the following are present and InterQual criteria are met:

An FDA-approved prosthetic intervertebral disc is utilized.

Treating individuals with only one level or two contiguous levels of cervical degenerative disc disease (C3-C7).

Skeletally mature individual with radiculopathy and/or myelopathy.

The arthroplasty will be performed at all symptomatic contiguous levels (up to two levels between C3-C7).

Radiographically confirmed complete arthrodesis of a previous cervical spinal fusion at another level (adjacent or non-adjacent).

Refer to Definitions for radiographic criteria (bridging trabecular bone, absence of lucency/hardware loosening, <1 mm motion on flexion-extension radiographs).

Cervical TADR - Not Medically Necessary / Unproven

Not covered when performed under the following conditions:

Cervical total artificial disc replacement performed at one level combined with cervical spinal fusion surgery at another level (adjacent or non-adjacent) as part of the same surgical plan (Hybrid Cervical Surgery) — stated as unproven and not medically necessary.

Hybrid Cervical Surgery defined in Definitions; limited high-quality evidence for hybrid procedures

Lumbar Total Artificial Disc Replacement (LTDR) - Proven and Medically Necessary

Covered when ALL of the following are present and InterQual Client Defined criteria are met:

An FDA-approved prosthetic intervertebral disc is utilized.

Treating individuals with only single level of lumbar degenerative disc disease.

Skeletally mature individual.

Symptomatic intractable discogenic low back pain attributable to that level.

InterQual linkage: InterQual Client Defined CP: Procedures, Artificial Disc Replacement, Lumbar (Custom) - UHG must be met

Lumbar TDR - Evidence gaps / limitations

Policy notes evidence limitations and non-coverage implications (ANY of the following points indicate evidence gaps or limitations):

Insufficient evidence comparing LTDR with continued conservative nonsurgical treatment, posterior/transforaminal dynamic stabilization (PTDS), between LTDR devices, and for multilevel DDD.

Hayes 2022 and subsequent reviews noted these limitations.

Little evidence that LTDR reduces adjacent level disease (ALD); no definitive conclusions for this outcome.

Insufficient evidence for two-level LTDR (Hayes 2022 conclusion and subsequent reviews found no change).

Planned surgical technique and operative levels (number and location)

Psychosocial-behavioral evaluation for lumbar cases when indicated

Documentation of instability when applicable

Documentation Required

Radiographic Confirmation for Prior Cervical Fusion

Radiographic confirmation of a prior cervical fusion is required for TADR after previous fusion. Documentation must meet the "Radiographically Confirmed Complete Arthrodesis" definition: evidence of trabecular bone across the intervertebral space, absence of lucency between graft and endplate, absence of hardware loosening, and < 1 mm of motion between spinous processes on flexion-extension radiographs.

Trabecular bone across the intervertebral space
No lucency between graft and endplate
No hardware loosening
< 1 mm motion on flexion-extension radiographs

Billing Rule

Device FDA Approval Requirement

Billing and device rules: an FDA-approved prosthetic intervertebral disc must be used. For two-level cervical procedures, the device must be FDA-approved for two-level use (i.e., the specific device must have FDA approval for implantation at two contiguous cervical levels).

FDA-approved prosthetic intervertebral disc required
Two-level devices must be FDA-approved for two-level use

Documentation Required

Radiographic Confirmation Required for Cervical TADR After Prior Fusion

For cervical TADR performed after a prior fusion, radiographic confirmation of complete arthrodesis (see Radiographically Confirmed Complete Arthrodesis criteria) must be included in the submitted records. This is a separate actionable documentation requirement and will be reviewed in addition to InterQual criteria.

Include flexion-extension radiographs demonstrating < 1 mm motion
Include imaging evidence of trabecular bone bridging and absence of lucency
Include assessment of hardware integrity (no loosening)

Updated Clinical Evidence and References sections to reflect current information and archived prior policy version 2026T0437OO.