CurrentUnitedHealthcarePolicy CS121NJ.Q

Total Artificial Disc Replacement Spine Nj Cs

Defines medical necessity criteria, limits, and exclusions for cervical and lumbar total artificial disc replacement (TADR/TDR) for UnitedHealthcare members in New Jersey, including requirements for FDA-approved devices and references to InterQual clinical criteria; includes related coding and clinical evidence summaries.

Policy Summary

PayerUnitedHealthcare

PolicyTotal Artificial Disc Replacement Spine Nj Cs

Policy CodePolicy CS121NJ.Q

Change TypeRevisions clarifying coverage and exclusions

Effective Date03/01/2026

Next Review Date

Key ActionDocument and reference InterQual criteria and FDA approval status in the medical record and obtain prior authorization when applicable.

SourceLink

POLICY UPDATE CHANGES

Revised cervical criteria to state cervical total artificial disc replacement is proven and medically necessary when all listed criteria and InterQual criteria are met, including device FDA-approval, symptomatic one- or two-contiguous level disease (C3-C7), skeletally mature with radiculopathy/myelopathy, and arthroplasty performed at all symptomatic contiguous levels.

Clarified cervical TADR is proven and medically necessary for individuals with prior cervical spinal fusion when all listed criteria and InterQual criteria are met, including radiographically confirmed complete arthrodesis of previous fusion at another level.

Revised lumbar criteria to state lumbar total artificial disc replacement is proven and medically necessary only for single-level lumbar degenerative disc disease when InterQual Client Defined criteria are met and an FDA-approved device is utilized.

Added language that cervical artificial disc removal or replacement is medically necessary for implant failure after prior disc replacement.

Clarified that cervical TADR combined with fusion at another level as part of the same surgical plan (hybrid surgery) is unproven and not medically necessary.

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

Added/clarified that medical records documentation may be required to assess whether the member meets criteria and must include history, physical exam, diagnostic results, and documentation of device FDA-approval status when applicable.

1-2Covered cervical contiguous levels (C3-C7)

1Covered lumbar levels

Not coveredHybrid surgery (TDR+fusion same plan)

YesInterQual required

FDA-approvedTwo-level cervical device requirement

03/01/2026Policy revision effective

Coverage Summary

Medical-Necessity Criteria

Cervical Total Artificial Disc Replacement (TADR) - Primary (no prior fusion)

Cervical total artificial disc replacement (TADR) — Primary (no prior fusion). Covered when ALL of the following are met and InterQual criteria are satisfied:

ALL of the following

An FDA-approved prosthetic intervertebral disc is utilized (device labeling must support the intended use).
Individual diagnosed with one or two contiguous levels of cervical degenerative disc disease between C3 and C7.
Skeletally mature individual with radiculopathy and/or myelopathy attributable to the target level(s).

Policy Summary

PayerUnitedHealthcare

PolicyTotal Artificial Disc Replacement Spine Nj Cs

Policy CodePolicy CS121NJ.Q

Change TypeRevisions clarifying coverage and exclusions

Effective Date03/01/2026

Next Review Date

Key ActionDocument and reference InterQual criteria and FDA approval status in the medical record and obtain prior authorization when applicable.

SourceLink

On This Page

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

For two-level contiguous cervical TADR, the device used must be FDA-approved for two-level use; when replacing a previously implanted cervical artificial disc, the second contiguous level device must be FDA-approved for two levels.

InterQual® CP: Procedures, Artificial Disc Replacement, Cervical criteria are met (refer to InterQual for specific clinical detail).

Cervical TADR - With History of Prior Cervical Spinal Fusion

Cervical TADR — With history of prior cervical spinal fusion. Covered when ALL of the following are met and InterQual criteria are satisfied:

ALL of the following

An FDA-approved prosthetic intervertebral disc is utilized (device labeling must support the intended use).
Treating individuals with one level or two contiguous levels of cervical degenerative disc disease (C3–C7).
Skeletally mature individual with radiculopathy and/or myelopathy attributable to the target level(s).
The arthroplasty will be performed at all symptomatic contiguous levels (up to two contiguous levels between C3–C7).
Radiographically confirmed complete arthrodesis of the prior cervical spinal fusion at another level (adjacent or non-adjacent).
Radiographically confirmed complete arthrodesis defined as trabecular bone across the intervertebral space, absence of lucency between graft and endplate, absence of hardware loosening and < 1 mm motion between spinous processes on flexion-extension radiographs.
InterQual® CP: Procedures, Artificial Disc Replacement, Cervical criteria are met (refer to InterQual for specific clinical detail).

Cervical Artificial Disc Removal or Replacement (implant failure)

Cervical artificial disc removal or replacement (implant failure). Covered when ALL of the following are met:

ALL of the following

Documented implant failure, malposition, loosening, subsidence, fracture, or other device-related complication requiring removal or revision of the cervical artificial disc.
Use of an FDA-approved prosthetic intervertebral disc for replacement (one- or two-level devices as applicable).
Clinical signs/symptoms and imaging findings consistent with implant failure and correlating with the level to be revised.
Reason for revision and planned procedure documented in the medical record (operative plan consistent with device labeling).

Cervical TADR - Not Medically Necessary (Unproven)

Cervical TADR — Not medically necessary (Unproven)

ALL of the following

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).
Procedures or device uses that are not supported by sufficient evidence to demonstrate efficacy and safety for the proposed combination or configuration.

Lumbar Total Artificial Disc Replacement (TDR) - Primary

Lumbar total artificial disc replacement (TDR) — Primary. Covered when ALL of the following are met and InterQual Client Defined criteria are satisfied:

ALL of the following

An FDA-approved prosthetic intervertebral disc is utilized (device labeling must support the intended use).
Treating individuals with a single level of lumbar degenerative disc disease attributable to the symptomatic level.
Skeletally mature individual.
Symptomatic intractable discogenic low back pain attributable to that level despite appropriate conservative care and consistent with InterQual Client Defined CP: Procedures, Artificial Disc Replacement, Lumbar (Custom) - UHG.
InterQual® Client Defined CP: Procedures, Artificial Disc Replacement, Lumbar (Custom) - UHG criteria are met (refer to InterQual for specific clinical detail).

Lumbar TDR - Not Medically Necessary (Unproven)

Lumbar TDR — Not medically necessary (Unproven). Lumbar TDR is unproven and not medically necessary when any of the following apply:

ANY of the following

Performed at one level combined with an existing lumbar spinal fusion surgery at another level (adjacent or non-adjacent).
Performed with lumbar spinal fusion surgery as part of the same surgical plan (Hybrid Lumbar Surgery).
Performed at more than one spinal level (i.e., multilevel lumbar TDR).

Cervical Total Artificial Disc Replacement - Proven / Medically Necessary (per 03/01/2026 revisions)

Cervical Total Artificial Disc Replacement — Proven / Medically Necessary (per 03/01/2026 revisions). Scenarios considered proven and medically necessary include:

ALL of the following

Primary cervical TADR at one or two contiguous levels (C3–C7) meeting the primary criteria and InterQual cervical criteria.
Cervical TADR performed in individuals with prior cervical fusion at a different level when radiographically confirmed complete arthrodesis is present and InterQual criteria are met.
Cervical artificial disc removal or replacement for documented implant failure when the revision meets the implant-failure criteria and an FDA-approved device is used.

Cervical Total Artificial Disc Replacement - Additional Proven Scenarios

Cervical Total Artificial Disc Replacement — Additional proven scenarios (clarifying coverage permutations):

ANY of the following

Replacement of a previously implanted cervical artificial disc for device failure when a replacement device is FDA-approved for the indicated number of levels and clinical/imaging documentation supports revision.
Two-level contiguous cervical TADR using a device with FDA approval for two-level contiguous use.

Cervical Artificial Disc Removal or Replacement - Proven

Cervical Artificial Disc Removal or Replacement — Proven

ALL of the following

Documented implant failure, malposition, loosening, subsidence, fracture, infection, or other device-related complication necessitating removal or replacement.
Use of an FDA-approved prosthetic intervertebral disc for replacement consistent with device labeling (one- or two-level as applicable).
Clinical and radiographic evidence correlating the device complication to the patient’s symptoms and the planned revision level(s).

Cervical Total Artificial Disc Replacement - Not Medically Necessary / Unproven

Cervical Total Artificial Disc Replacement — Not Medically Necessary / Unproven (summary of exclusions):

ANY of the following

Hybrid cervical surgery: cervical TADR at one level combined with cervical fusion at another level performed as part of the same surgical plan (adjacent or non-adjacent).
Use of devices or device configurations not supported by FDA approval for the intended level(s) or number of contiguous levels.
Procedures lacking sufficient evidence of safety and efficacy for the proposed indication or combination.

Lumbar Total Artificial Disc Replacement - Proven / Medically Necessary (per 03/01/2026 revisions)

Lumbar Total Artificial Disc Replacement — Proven / Medically Necessary (per 03/01/2026 revisions). Scenarios considered proven and medically necessary include:

ALL of the following

Primary single-level lumbar TDR using an FDA-approved prosthetic intervertebral disc and meeting InterQual Client Defined lumbar criteria.
Skeletally mature individuals with symptomatic intractable discogenic low back pain attributable to the treated level and inadequate response to appropriate conservative management.

Lumbar Total Artificial Disc Replacement - Not Medically Necessary / Unproven

Lumbar Total Artificial Disc Replacement — Not Medically Necessary / Unproven (summary):

ANY of the following

Multilevel lumbar TDR (more than one spinal level).
Lumbar TDR performed concurrently with lumbar fusion as part of the same surgical plan (Hybrid Lumbar Surgery).
Lumbar TDR performed at one level combined with an existing lumbar fusion at another level (adjacent or non-adjacent).

Cervical Total Artificial Disc Replacement - Medically Necessary

Cervical Total Artificial Disc Replacement — Medically Necessary (concise):

ALL of the following

FDA-approved device for intended use and levels.
One- or two-level contiguous cervical DDD (C3–C7) with radiculopathy and/or myelopathy.
Skeletally mature patient and procedure performed at all symptomatic contiguous levels (up to two).
InterQual cervical criteria met.

Cervical TADR - Prior Cervical Fusion (Medically Necessary)

Cervical TADR — Prior cervical fusion (Medically Necessary)

ALL of the following

FDA-approved prosthetic intervertebral disc for the intended use and levels.
One or two contiguous levels of cervical DDD (C3–C7) targeted for arthroplasty.
Skeletally mature individual with radiculopathy and/or myelopathy attributable to the target level(s).
Radiographically confirmed complete arthrodesis of a previous cervical fusion at a different level (adjacent or non-adjacent).
InterQual cervical criteria met.

Cervical Artificial Disc Removal or Replacement - Medically Necessary

Cervical Artificial Disc Removal or Replacement — Medically Necessary (concise):

ALL of the following

Documented implant failure or device-related complication requiring removal or replacement.
Replacement device is FDA-approved for the intended number of levels and used consistent with labeling.
Clinical and radiographic evidence supports revision at the planned level(s).

Cervical TADR - Not Medically Necessary

Cervical TADR — Not Medically Necessary (summary):

ANY of the following

Hybrid cervical surgery (simultaneous cervical TADR and fusion at different levels as part of the same plan).
Use of devices without FDA approval for the requested number of contiguous levels.

Lumbar Total Artificial Disc Replacement - Medically Necessary

Lumbar Total Artificial Disc Replacement — Medically Necessary (concise):

ALL of the following

FDA-approved device for single-level lumbar TDR and InterQual Client Defined lumbar criteria are met.
Skeletally mature individual with symptomatic intractable discogenic low back pain attributable to that single level after adequate conservative therapy.

Lumbar TDR - Not Medically Necessary / Unproven

Lumbar TDR — Not Medically Necessary / Unproven (concise):

ANY of the following

Multilevel lumbar TDR (more than one level).
Concurrent lumbar TDR and fusion as part of the same surgical plan (Hybrid Lumbar Surgery).
Lumbar TDR combined with an existing lumbar fusion at another level (adjacent or non-adjacent).

Two-Level Cervical TADR - Device Approval Requirement

Two-level contiguous cervical TADR — Device approval requirement. Device-level FDA approval requirements apply as follows:

ALL of the following

Two-level contiguous cervical TADR (replacement at two adjacent levels between C3 and C7) must be performed using a prosthetic intervertebral disc that has explicit FDA approval for two-level contiguous use.
When performing replacement after a prior cervical TADR, the replacement device(s) used at the adjacent level(s) must be FDA-approved for the proposed configuration (including two-level approvals when applicable).
If device labeling does not support two-level contiguous use (or the specific revision scenario), the procedure is considered not medically necessary due to lack of approved device for that use.

Cervical Total Artificial Disc Replacement - Proven / Medically Necessary

Cervical Total Artificial Disc Replacement — Proven / Medically Necessary (summary). This block restates proven indications:

ALL of the following

Primary one- or two-level contiguous cervical TADR (C3–C7) meeting device FDA approval and InterQual cervical criteria.
Cervical TADR after prior fusion with radiographically confirmed complete arthrodesis at a different level when InterQual criteria are met.
Revision (removal or replacement) for documented implant failure using FDA-approved replacement device(s).

Cervical Total Artificial Disc Replacement - Unproven / Not Medically Necessary

Cervical Total Artificial Disc Replacement — Unproven / Not Medically Necessary (summary). Unproven uses include:

ANY of the following

Hybrid cervical surgery (simultaneous TADR at one level and fusion at another as part of same operative plan).
Use of devices or configurations lacking FDA approval for the intended number of contiguous levels or revision scenario.

Lumbar Total Artificial Disc Replacement - Proven / Medically Necessary

Lumbar Total Artificial Disc Replacement — Proven / Medically Necessary (summary). Restates lumbar proven indication:

ALL of the following

Primary single-level lumbar TDR using an FDA-approved prosthetic intervertebral disc and meeting InterQual Client Defined lumbar criteria.
Skeletally mature individual with symptomatic intractable discogenic low back pain attributable to the treated level and inadequate response to conservative care.

Lumbar Total Artificial Disc Replacement - Unproven / Not Medically Necessary

Lumbar Total Artificial Disc Replacement — Unproven / Not Medically Necessary (summary). Restates lumbar unproven exclusions:

ANY of the following

Multilevel lumbar TDR (more than one spinal level).
Lumbar TDR performed with concurrent fusion as part of the same surgical plan (Hybrid Lumbar Surgery).
Lumbar TDR at one level combined with an existing lumbar fusion at another level (adjacent or non-adjacent).

Not Medically Necessary Conditions for Lumbar TADR

Not medically necessary conditions for lumbar TDR (concise list):

ANY of the following

More than one spinal level (multilevel lumbar TDR).
Concurrent lumbar fusion and TDR performed as part of the same operative plan (Hybrid Lumbar Surgery).
Lumbar TDR combined with an existing lumbar spinal fusion at another level.

Not Medically Necessary / Unproven Scenarios

Coding

Primary and Revision Procedure Codes (reference list)CPT

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; 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; 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

State Fee Schedule Note (New Jersey Medicaid)CPT

0098T	Not on the State of New Jersey Medicaid Fee Schedule (asterisked in Applicable Codes)
0165T	Not on the State of New Jersey Medicaid Fee Schedule (asterisked in Applicable Codes)

FDA device/product references (informational)mixed

MJO	FDA device/product reference code (informational)

Referenced Clinical Criteria Sourceother

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

Referenced clinical criteria for lumbar TDR (InterQual Client Defined, CP: Procedures, Artificial Disc Replacement, Lumbar - Custom UHG)

Provider Actions

Note