CurrentUnitedHealthcarePolicy CSNCT0437.08

Total Artificial Disc Replacement for the Cervical Spine (for North Carolina Only)

Defines UnitedHealthcare's policy for cervical total artificial disc replacement applicable only to North Carolina and references state Medicaid clinical coverage criteria for medical necessity. Affects providers requesting coverage for cervical total disc arthroplasty for North Carolina members.

Policy Summary

PayerUnitedHealthcare

PolicyTotal Artificial Disc Replacement for the Cervical Spine (for North Carolina Only)

Policy CodePolicy CSNCT0437.08

Change TypeDocumentation language added

Effective Date03/01/2026

Next Review Date

Key ActionObtain prior authorization per plan/federal/state/contractual requirements and ensure medical records fully document medical necessity for NC members.

SourceLink

POLICY UPDATE CHANGES

Added detailed Medical Records Documentation language specifying that benefit coverage is determined by federal, state, or contractual requirements and that medical records documentation may be required and must support medical necessity.

North Carolinajurisdiction

NC Medicaid 1A-30medical necessity source

7 codesprocedure codes

03/01/2026effective

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Coverage and Medical Necessity Criteria

Medical necessity — delegation to NC Medicaid 1A-30

Coverage and medical necessity are determined by the North Carolina Medicaid Clinical Coverage Policy 1A-30.

Delegation: Medical necessity criteria for cervical total disc replacement follow NC Medicaid Physician Clinical Coverage Policy 1A-30; providers must meet that policy's ALL criteria for coverage determinations.

See referenced policy for specific clinical inclusion/exclusion criteria

Codes in the applicable codes list that are marked with an asterisk (*) are not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the State of North Carolina Medicaid Program. Providers should confirm state fee schedule coverage and billing guidance before submitting claims for these codes.

This policy defers medical necessity determinations for cervical total disc arthroplasty to the North Carolina Medicaid (Division of Health Benefits) Clinical Coverage Policy, Physician: 1A-30, Spinal Surgeries. Providers seeking coverage must meet the clinical criteria set forth in NC Medicaid Policy 1A-30 and follow any applicable prior authorization and documentation requirements referenced therein.

Procedure and Billing Codes

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)
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.
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).
22861	Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical
22864	Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical.
22899	Unlisted procedure, spine

Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization required. Providers must obtain prior authorization per the North Carolina Medicaid (Division of Health Benefits) Clinical Coverage Policy, Physician: 1A-30, Spinal Surgeries before scheduling or performing services covered by this policy.

Prior authorization requirement is tied to NC Medicaid clinical criteria (Physician: 1A-30, Spinal Surgeries).
Providers should submit authorization requests according to UnitedHealthcare prior authorization processes and include all required documentation.

Documentation Required

Documentation Required for Reviews

The patient's medical record must contain documentation that fully supports the medical necessity for the requested services. This documentation should be legible, maintained in the patient's medical record, and made available upon request.

Documentation includes, but is not limited to: relevant medical history, physical examination, results of pertinent diagnostic tests or procedures (e.g., imaging), and operative reports when applicable.

Clinical Background

Total disc arthroplasty (artificial disc replacement) of the cervical spine is described here as an anterior approach procedure that replaces the intervertebral disc and decompresses neural elements. The procedure codes listed in this policy correspond to an anterior-approach cervical total disc arthroplasty, including associated discectomy and end-plate preparation; specific clinical inclusion/exclusion criteria and medical necessity are determined by NC Medicaid Policy 1A-30.

Definitions and Procedure Description

Cervical total disc arthroplasty (procedure) — definition of total disc arthroplasty, anterior approach, including discectomy with end plate preparation

DefinitionTotal disc arthroplasty (artificial disc), anterior approach — a surgical anterior-approach procedure for cervical interspaces that replaces the disc and decompresses neural elements; includes discectomy with end plate preparation.

IncludesDiscectomy with end plate preparation; may include osteophytectomy for nerve root or spinal cord decompression and microdissection as part of the procedure description for single interspace and second-level procedures.

Related procedures (examples)0098T (revision including replacement, each additional interspace), 22856 (primary, single interspace), 22858 (second level), 22861 (revision, single interspace), 22864 (removal, single interspace), 22899 (unlisted procedure, spine).

Coding noteDescriptions for CPT codes 22856 and 22858 explicitly state ‘including discectomy with end plate preparation’ in the anterior-approach total disc arthroplasty procedure descriptions.