CurrentUnitedHealthcarePolicy CS121OH.C

Total Artificial Disc Replacement Spine Oh Cs

UnitedHealthcare medical policy (Ohio only) governing cervical and lumbar total artificial disc replacement (TDR/ADR), including indications, exclusions (hybrid and multi-level procedures), applicable clinical criteria references (InterQual), coding references, documentation requirements, and evidence summaries regarding safety and effectiveness.

Policy Summary

PayerUnitedHealthcare

PolicyTotal Artificial Disc Replacement Spine Oh Cs

Policy CodePolicy CS121OH.C

Change TypeRevision — hybrid/multilevel exclusions clarified

Effective DateMar 1, 2026

Next Review Date

Key ActionProviders must supply legible medical records including history, physical exam, and diagnostic test results to support medical necessity and make them available upon request.

SourceLink

POLICY UPDATE CHANGES

Replaced prior language to make cervical artificial disc removal or replacement proven and medically necessary for implant failure after prior disc replacement.

Changed stance to state cervical total artificial disc replacement is unproven and not medically necessary when combined with cervical fusion at another level as part of the same surgical plan (hybrid cervical surgery).

Added language that lumbar total artificial disc replacement is unproven and not medically necessary when performed with existing lumbar fusion at another level or when performed with fusion as part of the same surgical plan (hybrid lumbar surgery).

Added language that medical records documentation may be required to assess whether member meets clinical criteria but does not guarantee coverage.

Added language clarifying that benefit coverage is determined by federal, state, or contractual requirements and that medical records documentation may be required to assess clinical criteria but does not guarantee coverage.

Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage.

Updated definition of 'Skeletally Mature'.

Updated Clinical Evidence and References sections to reflect the most current information.

Archived previous policy version CS121OH.B.

Clarified that medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage.

1State scope (Ohio-only)

Cervical: implant failureCovered indication summary

Hybrid/multilevel not coveredCommon exclusions

Multiple reviews/RCTsEvidence base cited

03/01/2026Policy revision date

Coverage Summary

Scope: This is a UnitedHealthcare medical policy for the state of Ohio addressing cervical and lumbar total artificial disc replacement (TDR/ADR).

Coverage stance: Mixed — some cervical revision/replacement for implant failure is covered, while several hybrid and multilevel procedures are considered unproven and not medically necessary.

Key covered indication (highlight): Cervical artificial disc removal or replacement with an FDA‑approved one‑ or two‑level prosthetic intervertebral disc is proven and medically necessary for individuals with implant failure after prior disc replacement.

Common exclusions / not medically necessary scenarios: Hybrid cervical surgery (one‑level ADR combined with cervical fusion at another level as part of the same surgical plan) is unproven and not medically necessary; hybrid lumbar surgery, lumbar ADR performed with an existing lumbar fusion at another level, and multilevel lumbar ADR (more than one level) are also considered unproven and not medically necessary.

Cervical — Medical Necessity Criteria

Covered when ALL of the following are met:

ALL of the following

Documentation meets the General Documentation Requirement (see Medical Records Documentation Used for Reviews).
General provider documentation must support medical necessity including history, exam, and pertinent diagnostics.
Documentation meets the Medical Records Documentation Requirement (see Medical Records Documentation Used for Reviews).
Complete medical record must be available on request to support the request.
Proven / Medically Necessary
- Cervical artificial disc removal or replacement with an FDA-approved (one or two-level) prosthetic intervertebral disc for implant failure after prior disc replacement.
  Per InterQual® CP: Procedures, Artificial Disc Replacement, Cervical.

Lumbar — Medical Necessity Criteria

Lumbar - Coverage Statements and Exceptions

Policy statements for lumbar artificial disc replacement:

ALL of the following

InterQual reference: For medical necessity clinical coverage criteria, refer to the InterQual® CP: Procedures, Artificial Disc Replacement, Lumbar.
Unproven / Not medically necessary scenarios
- Existing fusion at another level: Lumbar total artificial disc replacement is unproven and not medically necessary due to insufficient evidence of efficacy when performed at one level combined with an existing lumbar spinal fusion surgery at another level (adjacent or nonadjacent).
- Hybrid lumbar surgery:

Documentation & Provider Actions

Documentation Required

Maintain complete medical record documentation

Support medical necessity with full medical record. Maintain legible, complete documentation in the patient's medical record that supports the medical necessity for the requested services. This documentation must be made available upon request and may be required to assess whether the member meets clinical criteria for coverage.

Required elements: relevant medical history (including onset, prior treatments, conservative care and response), focused physical examination findings, and results of pertinent diagnostic tests or procedures (imaging reports, EMG/NCS if performed, prior operative notes).
Documentation should include dates, treating provider(s), and symptom severity and functional limitations.
Maintain documentation of prior conservative management and rationale for proceeding to artificial disc replacement.

Prior Authorization

Coding

Applicable 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.

Informational - FDA product regulation referencemixed

MJO	FDA product code referenced for artificial discs (informational only)

Background & Evidence Summary

Background: Total artificial disc replacement (TDR/ADR) replaces a degenerating intervertebral disc to preserve range of motion and reduce pain by implanting a prosthetic disc in the cervical or lumbar spine.

Evidence base: The policy cites InterQual as the primary clinical selection tool and summarizes a mixed evidence base — randomized trials and meta-analyses show single‑level lumbar TDR can be comparable or superior to fusion in selected patients, but longer‑term durability and broader applicability remain uncertain.

Specific concerns: There is limited or insufficient high‑quality evidence to support multilevel and hybrid constructs in many scenarios; hybrid cervical and lumbar procedures and multilevel lumbar TDR have heterogeneous study designs, variable implants, and limited long‑term data, and are therefore described as unproven/not medically necessary in several contexts.

Clinical selection: InterQual criteria are referenced for detailed medical necessity determinations for both cervical and lumbar artificial disc replacement; NASS guidance and multiple evidence reviews (ECRI, Hayes) are also cited to inform indications and contraindications.

Definitions

Term	Definition
Skeletally Mature
The classification of bone when endochondral ossification ceases and the physis 'closes' by becoming totally ossified (Reith, 2018). Definition updated in this revision.
Hybrid Surgery (HS/HC)
Artificial disc replacement at one level combined with spinal fusion surgery at another level (adjacent or non-adjacent). Concurrent use of total disc arthroplasty at one or more levels combined with anterior lumbar interbody fusion (ALIF) or other fusion at another level during the same procedure or existing fusion at another level. (Term and examples appear in policy; hybrid constructs are discussed as unproven/not medically necessary in some scenarios).
DDD
Degenerative disc disease.
TDR/TDA
Total disc replacement / total disc arthroplasty — replacement of a degenerating intervertebral disc with an artificial disc intended to preserve range of motion and reduce pain.

Revision History

03/01/2026material revisionLatest

Policy revision (03/01/2026): Clarified cervical implant failure indication — cervical artificial disc removal or replacement with an FDA‑approved (one or two‑level) prosthetic intervertebral disc is proven and medically necessary for implant failure after prior disc replacement; and specified that cervical total artificial disc replacement is unproven and not medically necessary when performed at one level combined with cervical fusion at another level as part of the same surgical plan (hybrid cervical surgery).

03/01/2026material revisionLatest

Policy revision (03/01/2026): Added lumbar hybrid/multilevel language — lumbar total artificial disc replacement is unproven and not medically necessary when performed at one level combined with an existing lumbar fusion at another level, when performed with fusion as part of the same surgical plan (hybrid lumbar surgery), or when performed at more than one spinal level; removed prior language that lumbar TDR was proven and medically necessary in certain single‑level circumstances.

Policy Summary

PayerUnitedHealthcare

PolicyTotal Artificial Disc Replacement Spine Oh Cs

Policy CodePolicy CS121OH.C

Change TypeRevision — hybrid/multilevel exclusions clarified

Effective DateMar 1, 2026

Next Review Date

Key ActionProviders must supply legible medical records including history, physical exam, and diagnostic test results to support medical necessity and make them available upon request.

SourceLink

On This Page

Lumbar total artificial disc replacement is unproven and not medically necessary when performed with lumbar spinal fusion surgery as part of the same surgical plan (hybrid lumbar surgery).

Multilevel (>1) lumbar ADR: Lumbar total artificial disc replacement is unproven and not medically necessary when performed at more than one spinal level.

NASS 2024 Indications and Contraindications for Lumbar Artificial Disc Replacement

Lumbar artificial disc replacement is indicated when ALL of the following are met:

NASS 2024 Indications - all required

Anatomic levels: Pain arising from 1- or 2-level disc disruption involving L3-4, L4-5, and/or L5-S1 segments.
Duration and nonoperative management: Presence of symptoms for at least six months or greater and not responsive to multi-modal nonoperative treatment over that period (should include physical therapy/rehabilitation and may include pain management, injections, cognitive behavioral therapy, and active exercise programs).>= 6 months
Primary symptom: Primary complaint of axial pain, with possible secondary lower extremity pain.

NASS 2024 Contraindications / Not Indicated - any apply

Does not meet indications: Case does not fulfill all of the above indication criteria.
Multilevel >2: Symptomatic degenerative disc disease at more than two levels.
Facet arthropathy: Significant facet arthropathy at the index level or signs the source of pain is primarily facet mediated.
Spondylolisthesis: Spinal instability with spondylolisthesis greater than Grade I.
Chronic radiculopathy (unremitting pain with predominance of leg pain symptoms greater than back pain symptoms, extending over a period of at least one year).

Prior authorization / Clinical criteria

Prior authorization and coverage determinations depend on meeting clinical criteria and applicable laws. InterQual clinical criteria are used to guide medical necessity determinations for artificial disc replacement procedures.

Apply InterQual clinical criteria: InterQual CP: Procedures, Artificial Disc Replacement (Cervical) and InterQual CP: Procedures, Artificial Disc Replacement (Lumbar) are referenced for cervical and lumbar indications respectively.
Coverage decisions will consider InterQual determinations along with federal, state (Ohio Administrative Code 5160-101), and contractual requirements.

Note

InterQual guidance

Use InterQual and other referenced guidelines when preparing requests and documentation. Clinical documentation submitted should align with the applicable InterQual CP and clearly demonstrate how the patient meets the stated criteria.

Include direct references to the InterQual criterion met when submitting prior authorization requests.
Ensure submitted records contain the specific diagnostic and clinical evidence cited by InterQual (e.g., imaging confirming level(s) of pathology, failure of conservative therapy).

Denial Risk

Denial risk — hybrid or multilevel procedures

Denial risk for hybrid or multilevel procedures. Hybrid procedures (combining ADR with fusion) and multilevel ADR procedures have increased risk of denial when they do not meet the policy clinical criteria or when evidence is insufficient.

Cervical hybrid surgery: ADR at one level combined with cervical spinal fusion at another level (adjacent or non-adjacent) performed as part of the same surgical plan — noted as unproven and not medically necessary.
Lumbar hybrid surgery: ADR performed with lumbar spinal fusion as part of the same surgical plan — noted as unproven and not medically necessary.
Multilevel lumbar ADR: ADR performed at more than one spinal level — noted as unproven and not medically necessary.
Denials may be issued if documentation does not clearly justify medical necessity per InterQual or applicable state law.

03/01/2026non-material clarificationLatest

Added and reiterated documentation and coverage clarification: benefit coverage is determined by federal, state, or contractual requirements and medical records documentation may be required to assess whether the member meets clinical criteria but does not guarantee coverage; the patient's record must fully support medical necessity and be made available upon request.

03/01/2026non-material revisionLatest

Updated definitions and supporting sections: definition of 'Skeletally Mature' updated and Clinical Evidence/References sections refreshed to reflect current information.

archived previous versionLatest

Previous policy version CS121OH.B archived.

non-material clarificationLatest

Clarified that documentation requirements are emphasized repeatedly throughout the policy and Policy History/Revision Information.

DEXA T-score: Osteopenia as evidenced by a DEXA bone mineral density T-score less than or equal to -1.0.<= -1.0

Psychiatric disorder: Poorly managed psychiatric disorder (underlying psychiatric disorder such as depression should be diagnosed and management optimized before surgical intervention).

Age limits: Age greater than 60 years or less than 18 years.18-60 years

Infection or tumor: Presence of infection or tumor.