ModifiedUnitedHealthcarePolicy CS121LA.N

Artificial intervertebral disc replacement (cervical and lumbar)

Medical policy governing use and coverage of FDA‑approved cervical and lumbar artificial total disc replacement and related hybrid surgeries for Louisiana Medicaid members; includes coverage rationale, definitions, and applicable procedure codes.

Policy Summary

PayerUnitedHealthcare

PolicyArtificial intervertebral disc replacement (cervical and lumbar)

Policy CodePolicy CS121LA.N

Change TypeMaterial revision — coverage language updated for lumbar TDR

Effective DateJun 1, 2025

Next Review Date

Key ActionObtain prior authorization documenting failed ≥6 months of multimodal nonoperative care and required clinical documentation before approval.

SourceLink

POLICY UPDATE CHANGES

Replaced language stating lumbar artificial total disc replacement is proven and medically necessary for single-level lumbar DDD with language that it is proven and medically necessary in certain circumstances.

Archived previous policy version CS121LA.M.

1–2cervical: covered levels (C3–C7)

singlelumbar: covered level

>1lumbar: not medically necessary beyond one level

6 mominimum failed nonsurgical management

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Retired Apr 1, 2026policy retirement note (LA-only)

Coverage Criteria

Cervical artificial disc replacement (medically necessary)

Covered when ALL of the following are met for cervical:

Cervical CADR criteria: Cervical artificial total disc replacement with an FDA‑approved prosthetic intervertebral disc is medically necessary for one‑level or two contiguous levels (C3–C7) in a skeletally mature individual with symptomatic radiculopathy and/or myelopathy.one or two contiguous levels

Refer to InterQual CP: Procedures, Artificial Disc Replacement, Cervical for full clinical criteria

Lumbar artificial disc replacement (medically necessary)

Covered when ALL of the following are met for lumbar:

Lumbar TDR criteria: Lumbar artificial total disc replacement with an FDA‑approved prosthetic intervertebral disc is medically necessary for single‑level lumbar degenerative disc disease with symptomatic intractable discogenic low back pain in a skeletally mature individual.single level

Refer to InterQual Client Defined CP: Procedures, Artificial Disc Replacement, Lumbar for full clinical criteria; evidence from RCTs and meta-analyses supports single‑level TDR in properly selected patients who have failed conservative treatment

CADR with prior cervical fusion (covered)

Prior fusion history: Cervical artificial disc replacement is medically necessary for one or two contiguous levels in a skeletally mature individual with a history of prior cervical spinal fusion at another level (adjacent or non‑adjacent).history of prior cervical fusion

Unproven / Not medically necessary

Unproven/not medically necessary: Cervical artificial disc replacement at one level combined with cervical spinal fusion at another level as part of the same surgical plan is unproven and not medically necessary; lumbar disc replacement at more than one level (multilevel LTDR) is unproven and not medically necessary due to insufficient evidence of efficacy.

Evidence-supported coverage scenarios

Coverage considerations where evidence supports TDR in selected patients:

Single-level lumbar TDR typical eligibility: Patients with symptomatic single‑level lumbar degenerative disc disease who have failed ≥6 months of multimodal nonsurgical management and meet device/trial selection criteria may have outcomes comparable or superior to fusion in selected randomized controlled trials and meta-analyses.>=6 months conservative management

Supported by multiple RCTs, systematic reviews and IDE studies (e.g., activL, ProDisc-L)

Cervical TDR after prior fusion: Small retrospective series report clinical improvement and preserved range of motion when CADR is performed for adjacent segment disease after prior ACDF in select patients; evidence is limited by small cohorts and short‑term follow‑up.none

Evidence limited by small sample sizes and short-term follow-up

Limited evidence / restricted coverage

Situations where evidence is insufficient or inconclusive:

Multilevel lumbar TDR or hybrid lumbar arthroplasty: There is insufficient high‑quality evidence demonstrating safety and efficacy for multilevel lumbar total disc replacement and for hybrid lumbar disc arthroplasty with fusion; published data are limited to abstracts, small cohorts, and few RCTs, and do not support routine use.

Hayes evidence reviews (2020–2024) identify minimal support and recommend further research; prior authorization and case‑by‑case review are appropriate for multilevel or hybrid constructs

Indications per NASS (as reflected in policy)

Covered when ALL of the following are met:

NASS indication cluster: 1) Pain arising from 1‑ or 2‑level disc disruption at L3‑4, L4‑5, and/or L5‑S1; 2) Symptoms ≥ 6 months unresponsive to multimodal nonoperative treatment (including physical therapy/rehabilitation; may include injections, pain management, cognitive behavioral therapy, and active exercise); 3) Primary complaint of axial low back pain (lower‑extremity pain may be secondary).>=6 months conservative management

Follow NASS selection and exclusion criteria; exclude patients with symptomatic disease at >2 levels, significant facet arthropathy, spinal instability (spondylolisthesis > Grade I), chronic predominant leg pain >1 year, DEXA T‑score ≤ -1.0, age >60 or <18, infection or tumor, or poorly managed psychiatric disorder

The policy states that lumbar artificial total disc replacement is unproven and not medically necessary at more than one spinal level. This reflects the limited published evidence for multilevel lumbar TDR and supports coverage only for single‑level lumbar degenerative disc disease when other criteria are met.

Systematic reviews and recent evidence summaries identify insufficient high‑quality data to demonstrate safety and long‑term efficacy of multilevel lumbar TDR or hybrid constructs combining disc arthroplasty with fusion. Hayes reviews (2023–2024) and meta‑analyses note small cohorts, abstracts, and heterogeneous designs; consequently these approaches lack robust supportive evidence and warrant restricted use or case‑by‑case review.

The policy incorporates NASS selection/exclusion considerations. Notable exclusions include symptomatic degenerative disc disease at more than 2 levels, significant facet arthropathy at the index level, and spinal instability with spondylolisthesis greater than Grade I. Other exclusion criteria called out by NASS and adopted in the policy include chronic predominately radicular pain >1 year, osteopenia with DEXA T‑score ≤ -1.0, poorly managed psychiatric disorder, age <18 or >60, and presence of infection or tumor.

Cervical artificial disc replacement performed at one level in combination with cervical spinal fusion at another level as part of the same surgical plan is explicitly considered unproven and not medically necessary because current evidence does not demonstrate efficacy for the combined procedure within a single operative plan.

The policy notes that routine use of hybrid lumbar arthroplasty (disc replacement combined with fusion) for multilevel degenerative disc disease is not supported by sufficient evidence. Published systematic reviews and evidence briefs report limited, heterogeneous data and recommend further prospective studies before routine adoption; therefore routine hybrid constructs for multilevel disease are not supported.

Guideline-level assessments caution against offering disc replacement for nonradicular low back pain outside of controlled study settings. The American Pain Society noted limited long‑term outcome data beyond 2 years, and NICE recommends that disc replacement not be offered for low back pain—supporting a recommendation against routine procedures for nonradicular low back pain without stronger evidence of long‑term benefit.

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

Regulatory/Product Codes (informational)mixed

MJO (FDA product code)

FDA product code for intervertebral disc prostheses

Minimum duration of failed nonoperative management

Minimum duration of failed nonoperative management>= 6 months of multimodal nonsurgical care documented (e.g., physical therapy/rehabilitation, injections, pain management) before consideration of TDR

Evidence basisIn many lumbar TDR trials (IDE/RCTs) enrollment required failure of at least 6 months of nonsurgical management

Prior authorization requirementPrior authorization must document failed >=6 months of multimodal nonoperative care for lumbar TDR

Allowed number of index levels

Allowed number of index levels (policy)Cervical: one or two contiguous levels (C3–C7); Lumbar: single level for routine coverage

Conditional/limited scenarios

Provider Actions & Authorization

Billing Rule

Procedure codes referenced

Reference the CPT and temporary procedure codes below when submitting claims and documentation for artificial disc replacement procedures. Inclusion in this policy does not guarantee coverage or payment; verify member benefits and contractual requirements.

* 0098T — Revision including replacement of total disc arthroplasty, cervical (additional interspace)
* 0165T — Revision including replacement of total disc arthroplasty, lumbar (additional interspace)
* 22856 — Total disc arthroplasty, cervical, single interspace
* 22857 — Total disc arthroplasty, lumbar, single interspace
* 22858 — Total disc arthroplasty, cervical, second level (add-on)
* 22860 — Total disc arthroplasty, lumbar, second interspace (add-on)
* 22861 — Revision including replacement of total disc arthroplasty, cervical, single interspace
* 22862 — Revision including replacement of total disc arthroplasty, lumbar, single interspace

Background

Artificial total disc replacement is a surgical procedure that removes a degenerated intervertebral disc and implants a prosthetic device intended to preserve range of motion at the treated level and reduce pain. Cervical procedures primarily address symptomatic radiculopathy and/or myelopathy, while lumbar procedures address intractable discogenic low back pain in skeletally mature adults who have failed nonoperative management.

Definitions

Skeletally Mature

Skeletally mature definitionThe apparent stage of development of the bones determined with radiological studies; used to assess growth and determine eligibility for disc replacement

Use in eligibilitySkeletal maturity must be documented (radiographic) to establish candidacy for artificial disc replacement

Typical assessmentRadiological studies are referenced to determine bone development stage

Hybrid construct (spine)

Hybrid construct (spine) definitionA surgical construct combining total disc replacement at one or more levels with spinal fusion (arthrodesis) at adjacent levels

Evidence noteData on multilevel hybrid constructs are limited and less robust than single-level CDA/TDR studies

Policy Summary

PayerUnitedHealthcare

PolicyArtificial intervertebral disc replacement (cervical and lumbar)

Policy CodePolicy CS121LA.N

Change TypeMaterial revision — coverage language updated for lumbar TDR

Effective DateJun 1, 2025

Next Review Date

Key ActionObtain prior authorization documenting failed ≥6 months of multimodal nonoperative care and required clinical documentation before approval.

SourceLink

On This Page

Lumbar 2-level or multilevel TDR or hybrid constructs lack sufficient evidence and may require case-by-case review or be considered not medically necessary

NASS constraintNASS guidance excludes symptomatic degenerative disc disease at >2 levels from candidate pool

DEXA T-score exclusion threshold

DEXA T-score exclusion thresholdDEXA T-score <= -1.0 (osteopenia) is an exclusion per NASS criteria

ImplicationPatients with T-score <= -1.0 are at higher risk and may be ineligible for disc arthroplasty

DocumentationDEXA results should be provided in prior authorization/medical record to demonstrate bone density

* 22899 — Unlisted procedure, spine

Codes labeled with an asterisk (*) may not be on the State of Louisiana Medicaid Fee Schedule

Prior Authorization

Prior authorization recommended for multilevel TDR/hybrid

Prior authorization is recommended when considering multilevel lumbar total disc replacement (TDR) or hybrid constructs (TDR combined with fusion). Submit a prior authorization request to allow clinical review given evidence limitations for multilevel procedures.

Prior authorization recommended for multilevel (more than one level) lumbar TDR or hybrid TDR + fusion constructs
Include detailed operative plan if contemplating combining TDR with fusion in the same surgical episode

Denial Risk

Evidence insufficiency for multilevel lumbar TDR/Hybrid

Published evidence is insufficient to support routine coverage of multilevel lumbar TDR or hybrid TDR with fusion. Cases proposing multilevel or hybrid constructs may be denied or require additional documentation and stronger evidence (IDE/randomized trial data) to be considered.

Insufficient published clinical evidence for safety and long-term efficacy of multilevel lumbar TDR
Hybrid constructs (TDR + fusion) have minimal/uncertain support in current literature
Provide randomized/IDE trial evidence when available to support coverage requests for multilevel/hybrid procedures

Documentation Required

Skeletal maturity requirement

Skeletal maturity must be documented (radiologically) for all candidates for artificial disc replacement. Lack of documented skeletal maturity may render the procedure ineligible.

Confirm and document skeletal maturity using radiological studies prior to authorization or surgery

Documentation Required

Required clinical documentation

Provide the following minimum clinical documentation when requesting prior authorization or when filing claims for artificial disc replacement procedures. Incomplete documentation may delay review or result in denial.

Symptom duration and clinical history showing persistent symptoms ≥ 6 months
Documentation of failed nonsurgical management (conservative therapy) for ≥ 6 months, including physical therapy, medications, injections, and other modalities as appropriate
Relevant imaging reports (MRI, X-rays) demonstrating degenerative disc disease at the index level(s) and absence of exclusionary findings (e.g., significant facet arthropathy, instability, infection, tumor)
Radiologic evidence confirming skeletal maturity
Operative plan when multilevel or hybrid constructs are being considered
Prior surgical history (if prior lumbar or cervical surgery) and supporting records
Documentation addressing NASS selection/exclusion criteria when applicable (e.g., spondylolisthesis grade, DEXA results if osteopenia suspected, psychiatric evaluation if indicated)

Note

Use of InterQual for medical necessity

InterQual criteria are used for medical necessity determinations for cervical and lumbar artificial disc replacement. Reference and apply the appropriate InterQual module when submitting prior authorization requests or clinical documentation.

InterQual CP: Procedures, Artificial Disc Replacement, Cervical
InterQual Client Defined CP: Procedures, Artificial Disc Replacement, Lumbar (Custom) - UnitedHealth Group

Documentation Required

Conservative therapy prior to TDR

A trial of conservative therapy is a prerequisite for lumbar and cervical TDR in candidates without acute indications. Document at least 6 months of appropriate nonoperative management unless there is a clear contraindication or other extenuating circumstance.

Conservative therapy prior to TDR: minimum 6 months of documented nonoperative care (physical therapy/rehabilitation and other modalities such as medications, injections as clinically appropriate)
Document specific therapies tried, duration, response, and reasons for failure prior to considering TDR

Clinical implicationHybrid constructs may be considered in select cases but often warrant additional review or prior authorization due to limited evidence

Adjacent segment disease (ASD)

Adjacent segment disease (ASD) definitionNew or progressive degenerative changes at spinal levels adjacent to a prior fusion; may present with radiculopathy or axial pain

Relation to revision approachesTDR (CTDR/ACDR) has been used as a revision approach for ASD after prior fusion with reports of maintained ROM and clinical improvement in small series

Evidence limitationsExisting studies are small retrospective series with limited follow-up

Lumbar degenerative disc disease (DDD)

Lumbar degenerative disc disease (DDD) definitionDiscogenic low back pain arising from 1- or 2-level disc disruption (commonly L3-4, L4-5, L5-S1) not responsive to multimodal nonoperative care

Typical presentationPrimary axial low back pain, possible secondary lower-extremity symptoms, and imaging confirming 1- or 2-level disc disruption

Eligibility noteSingle‑level symptomatic lumbar DDD unresponsive to >=6 months nonsurgical management is the usual indication evaluated in RCTs/IDE trials

Hybrid surgery

Hybrid surgery definitionA construct combining total disc arthroplasty at one level with anterior discectomy/fusion (arthrodesis) at an adjacent level

Distinction from multilevel TDRHybrid surgery differs from multilevel TDR by combining arthroplasty and fusion at adjacent levels rather than performing TDR alone at multiple levels

Evidence statusThere is a limited body of literature investigating hybrid lumbar disc replacement constructs; evidence for efficacy/safety is insufficient