CurrentUnitedHealthcarePolicy CS121NJ.Q

Total Artificial Disc Replacement Spine Nj Cs

State-specific UnitedHealthcare medical policy (New Jersey) defining medical necessity criteria, coverage limitations, and applicable coding for cervical and lumbar total artificial disc replacement (TADR/TDR), including indications, exclusions (hybrid surgeries and multilevel lumbar), documentation expectations, and referenced InterQual criteria.

Policy Summary

PayerUnitedHealthcare

PolicyTotal Artificial Disc Replacement Spine Nj Cs

Policy CodePolicy CS121NJ.Q

Change TypeRevised coverage; added exclusions/definitions

Effective DateMar 1, 2026

Next Review Date

Key ActionEnsure medical records document FDA approval of the device and meet InterQual criteria; provide radiographic confirmation of fusion for post-fusion cervical cases when applicable.

SourceLink

POLICY UPDATE CHANGES

Revised coverage rationale (03/01/2026) clarifying cervical and lumbar TADR/TDR medical necessity criteria and specifying unproven indications including hybrid and multilevel lumbar procedures.

Revised cervical coverage language to specify one- or two-level contiguous disease (C3-C7), skeletal maturity, radiculopathy/myelopathy, performance at all symptomatic contiguous levels (up to two), and InterQual criteria requirement.

Added coverage statement that cervical artificial disc removal or replacement with an FDA-approved (one or two-level) device is medically necessary for implant failure after prior disc replacement.

Revised lumbar coverage language to state lumbar TADR is medically necessary for single-level disease with symptomatic intractable discogenic low back pain and InterQual criteria met.

Clarified lumbar TADR is unproven and not medically necessary when performed with existing lumbar fusion at another level, as part of the same surgical plan (hybrid), or when performed at more than one spinal level.

Added and updated definitions to support coverage criteria (Contiguous Levels, Hybrid Cervical/Lumbar Surgery, Radiographically Confirmed Complete Arthrodesis, Skeletally Mature).

2Cervical: up to 2 contiguous levels (C3-C7)

1Lumbar: single level only

InterQualInterQual required for coverage

HybridHybrid surgeries (same operative plan) not covered

Revision OKRevision for implant failure (cervical) allowed

Coverage Summary

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:

ALL of the following

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).

Policy Summary

PayerUnitedHealthcare

PolicyTotal Artificial Disc Replacement Spine Nj Cs

Policy CodePolicy CS121NJ.Q

Change TypeRevised coverage; added exclusions/definitions

Effective DateMar 1, 2026

Next Review Date

Key ActionEnsure medical records document FDA approval of the device and meet InterQual criteria; provide radiographic confirmation of fusion for post-fusion cervical cases when applicable.

SourceLink

On This Page

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

ALL of the following

For two-level contiguous cervical total artificial disc replacement, the device being utilized must be FDA-approved for two levels.
When a cervical total artificial disc replacement was previously performed, any second contiguous level artificial disc to be implanted must be FDA-approved for two levels.

Cervical TADR After Prior Cervical Spinal Fusion — Medically Necessary

Cervical TADR After Prior Cervical Spinal Fusion — Medically necessary when ALL of the following are present and InterQual criteria are met:

ALL of the following

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

Cervical Artificial Disc Removal or Replacement — Medically Necessary

Cervical artificial disc removal or replacement is proven and medically necessary when ALL of the following are present:

ALL of the following

Implant failure after prior cervical disc replacement is documented.
An FDA-approved prosthetic intervertebral disc (one- or two-level as appropriate) is utilized for replacement when indicated.

Cervical Total Artificial Disc Replacement — Not Medically Necessary

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

ANY of the following

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).
Use of a cervical two-level device that is NOT FDA-approved for two-level use when performing two-level contiguous cervical TADR.
Implantation of a second contiguous level artificial disc after a prior cervical TADR when the second device is NOT FDA-approved for two-level use.

Lumbar Total Artificial Disc Replacement — Medically Necessary

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

ALL of the following

An FDA-approved prosthetic intervertebral disc is utilized.
Treating individuals with only a single level of lumbar degenerative disc disease.
Skeletally mature individual.
Symptomatic intractable discogenic low back pain attributable to that level.
InterQual criteria for Lumbar Artificial Disc Replacement are met (refer to InterQual Client Defined CP: Procedures, Artificial Disc Replacement, Lumbar - UHG).

Lumbar Total Artificial Disc Replacement — Not Medically Necessary / Unproven

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

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 (multilevel lumbar TADR).

Not Medically Necessary / Unproven Indications

Coding

Primary / Revision Cervical and Lumbar Procedure Codes (reference)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 (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.

Referenced regulatory/device requirementmixed

No codes listed

Referenced external criteriaother

InterQual

InterQual Client Defined, CP: Procedures, Artificial Disc Replacement, Lumbar (Custom) - UHG; and InterQual CP: Procedures, Artificial Disc Replacement, Cervical. Used as the medical necessity clinical coverage criteria referenced in this policy.

Provider Actions & Requirements

Note