Total Artificial Disc Replacement Spine Tn Cs

Coverage Summary

Policy: Total Artificial Disc Replacement for the Spine (CS121TN.V) for Tennessee Medicaid and CoverKids. Effective March 1, 2026 (policy header). Payer/Application: Tennessee Medicaid and CoverKids.

Coverage stance: Mixed — cervical TADR is covered (medically necessary) for carefully selected patients (one or two contiguous levels C3–C7, up to 2 contiguous levels) when InterQual criteria are met and device-level approvals are satisfied; lumbar TDR coverage is more limited — proven and medically necessary only for single-level lumbar disease when InterQual criteria are met and is considered unproven/not medically necessary for hybrid lumbar surgery, fusion-combined procedures, or procedures at >1 level (policy limits).

Key device/administrative requirements: an FDA‑approved prosthetic intervertebral disc must be used; InterQual clinical criteria must be met for coverage determinations; for two‑level cervical TADR the device must be FDA‑approved for two levels and when prior cervical TDR exists the second contiguous level device must be FDA‑approved for two levels.

Max allowed levels/statistics (policy thresholds): Max cervical contiguous levels covered = 2 (one or two contiguous levels between C3–C7); Max lumbar levels covered = 1 (single-level lumbar degenerative disc disease). Hybrid surgeries are treated as restricted/not medically necessary in specified contexts.

Coverage thresholds and key stats

Contiguous Levels (cervical)one or two contiguous levels between C3-C7

Max cervical contiguous levels covered2

Max lumbar levels covered1

Hybrid surgery statushybrid

Definitions added/updated4

Cervical Total Artificial Disc Replacement — Medically Necessary (Initial)

Cervical Total Artificial Disc Replacement - Medically Necessary

Covered when ALL of the following are met 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)

Cervical TADR After Prior Cervical Spinal Fusion — Medically Necessary

Cervical TADR After Prior Cervical Spinal Fusion - Medically Necessary

Covered when ALL of the following are met 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)

Cervical Artificial Disc Removal or Replacement — Medically Necessary

Cervical Artificial Disc Removal or Replacement - Medically Necessary

Covered when the following is present:

ALL of the following

FDA-approved (one or two-level) prosthetic intervertebral disc
Implant failure after prior disc replacement

Cervical Total Artificial Disc Replacement — Not Medically Necessary

Cervical Total Artificial Disc Replacement - Not Medically Necessary

TADR 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)

Lumbar Total Artificial Disc Replacement — Medically Necessary

Lumbar Total Artificial Disc Replacement - Medically Necessary

Covered when ALL of the following are met and InterQual criteria are met:

ALL of the following

An FDA-approved prosthetic intervertebral disc is utilized
Treating individuals with only single level of lumbar degenerative disc disease
Skeletally Mature individual
Symptomatic intractable discogenic low back pain attributable to that level

Lumbar Total Artificial Disc Replacement — Not Medically Necessary / Unproven

Lumbar Total Artificial Disc Replacement - Not Medically Necessary / Unproven

Not covered due to insufficient evidence when any of the following are present:

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

Cervical — Additional Medically Necessary Scenarios

Cervical Total Artificial Disc Replacement - Additional Medically Necessary Scenarios

Covered 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)

Definitions

Definitions (consolidated):

Contiguous Levels — vertebral segments adjacent to each other; for cervical coverage the policy specifies one or two contiguous levels between C3–C7 (definition: vertebral segments adjacent to each other).

Hybrid Cervical Surgery — combined anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA); the policy treats one‑level TADR combined with fusion at another level as not medically necessary/unproven in specified scenarios.

Hybrid Lumbar Surgery — combination of total disc arthroplasty (TDA) and anterior lumbar interbody fusion (ALIF); lumbar hybrid constructs are considered unproven/not medically necessary in many contexts per policy.

Radiographically Confirmed Complete Arthrodesis — imaging evidence of bridging 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 (required documentation for certain cervical TADR after prior fusion scenarios).

Skeletally Mature — bone classification when endochondral ossification ceases and the physis closes by becoming totally ossified (policy notes an updated wording was included).

Notes on duplicates/updates: the policy added/updated definitions for Contiguous Levels, Hybrid Cervical Surgery, Hybrid Lumbar Surgery, Radiographically Confirmed Complete Arthrodesis, and updated the definition of Skeletally Mature (definitions consolidated here reflect the policy's additions and revisions).

Supporting Evidence & Guidance

ECRI (2021) / Simplify: a 2021 ECRI assessment reported one prospective historical‑control trial (n=267) suggesting Simplify may be safe and more effective than ACDF at 24 months but noted limited evidence and high risk of bias — implications: promising but insufficient high‑quality evidence to change broad coverage beyond stated criteria.

Hayes reviews (2024–2025): multiple Hayes reports conclude minimal support for hybrid lumbar TDR with fusion and limited support for two‑level lumbar TDR; Hayes provides moderate‑quality evidence that single‑level LTDR is comparable to fusion in appropriately selected patients but insufficient evidence for multilevel lumbar TDR.

activL trial (post‑hoc analyses / prospective IDE data): 5‑year and trial analyses (activL) show maintained improvements for single‑level lumbar TDR and similar outcomes for patients with and without prior lumbar surgery — supports single‑level lumbar TDR in selected patients but does not establish multilevel or hybrid indications.

Radcliff et al. (2021): a 7‑year randomized IDE study (activL vs ProDisc‑L) reported sustained improvements in ODI and VAS with low reoperation rates at seven years — supports durability of single‑level lumbar TDR for selected patients.

Multiple meta‑analyses (2018–2021): pooled analyses generally favor TDR over fusion for ODI, VAS, satisfaction, and some reoperation outcomes, with mixed data on long‑term durability — informs policy favoring single‑level lumbar TDR in selected cases but caution for multilevel use.

NICE (2020): recommends not offering disc replacement for low back pain — represents a conservative guideline that influenced policy caution regarding lumbar disc replacement.

NASS (2024): indicates lumbar ADR may be indicated for 1–2 level discogenic low back pain under strict criteria and lists multiple exclusions; NASS also recognizes increasing evidence for hybrid cervical surgery but limited evidence for ≥3 levels — the policy aligns with selective cervical coverage and restrictive lumbar coverage.

Coding

Applicable Procedure Codes (reference only)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; 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; 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

FDA product code referencemixed

MJO	FDA product code for intervertebral body prostheses (informational reference only)

Provider Actions & Prior Authorization

Prior Authorization

InterQual criteria and documentation required

Coverage requires that InterQual clinical criteria be met; medical records documentation (history, physical exam, diagnostic test results) must support medical necessity and be made available upon request.

InterQual CP: Procedures, Artificial Disc Replacement, Cervical (referenced)
InterQual Client Defined CP: Procedures, Artificial Disc Replacement, Lumbar (Custom) - UHG (client-defined InterQual for lumbar)

Documentation Required

Radiographic confirmation of prior fusion

For TADR after prior cervical fusion, documentation must include radiographically confirmed complete arthrodesis (bridging trabecular bone, <1 mm motion on flexion-extension radiographs, absence of lucency/hardware loosening).

Revision History

03/01/2026material_changeLatest

Revised cervical coverage language to specify criteria for one- or two-level cervical TADR including requirement that device is FDA‑approved and InterQual criteria are met; for two-level contiguous cervical TADR the device must be FDA‑approved for two levels and when a prior cervical TADR was performed the second contiguous level device must be FDA‑approved for two levels; added criteria for TADR after prior cervical fusion requiring radiographically confirmed complete arthrodesis.

03/01/2026material_changeLatest

Revised lumbar coverage language to indicate lumbar TDR is proven and medically necessary only for single‑level disease with InterQual criteria met; clarified lumbar TDR is unproven/not medically necessary for hybrid lumbar surgery, when combined with fusion, or when performed at more than one level.