CurrentUnitedHealthcarePolicy CS121NM.C

Total Artificial Disc Replacement for the Spine (for New Mexico Only)

UnitedHealthcare medical policy (New Mexico only) defining medical necessity criteria, investigational/unproven exclusions, documentation requirements, applicable procedure codes, and supporting evidence summaries for cervical and lumbar total artificial disc replacement (TADR/LTDR), including rules for prior fusion and hybrid surgeries.

Policy Summary

PayerUnitedHealthcare

PolicyTotal Artificial Disc Replacement for the Spine (for New Mexico Only)

Policy CodePolicy CS121NM.C

Change TypeNo material change

Effective DateMar 1, 2026

Next Review Date

Key ActionEnsure the patient medical record contains relevant history, physical exam, and diagnostic results to support that InterQual and policy criteria are met and make documentation available upon request.

SourceLink

POLICY UPDATE CHANGES

No material changes

2Max Cervical Levels Covered (contiguous)

1Lumbar Levels Covered (single level only)

1State Applicability (New Mexico only)

Coverage Summary

This policy addresses Total Artificial Disc Replacement (cervical and lumbar) — surgical replacement of degenerated intervertebral discs intended to preserve range of motion and reduce pain. It applies to UnitedHealthcare coverage determinations for the state of New Mexico only and summarizes medical necessity rules, investigational/unproven exclusions, documentation requirements, and applicable procedure codes for cervical and lumbar TDR (TADR/LTDR).

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Evidence summaries note systematic reviews, randomized trials, cohort studies, and technology assessments (ECRI, Hayes, RCTs and meta-analyses) showing that properly selected single-level lumbar TDR can have outcomes comparable to fusion, and that cervical TDR is supported for up to two contiguous levels with more limited and heterogeneous evidence for hybrid or multilevel procedures. The policy differentiates cervical versus lumbar indications and limits (cervical: up to two contiguous levels C3–C7; lumbar: single level for primary coverage) and documents specific exclusions for hybrid surgeries and multilevel lumbar TDR where evidence is insufficient.

Applicable Procedure Codes

Applicable 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; 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

Provider Actions and Requirements

Documentation Required

Medical record documentation must support medical necessity

Patient medical record must contain relevant history, physical examination, and results of pertinent diagnostic tests or procedures that fully support that the coverage criteria are met; documentation should be legible, maintained in the patient's medical record, and made available upon request.

Relevant medical history
Physical examination findings
Results of pertinent diagnostic tests or procedures
Legible documentation accessible upon request

Prior Authorization

InterQual criteria required

Coverage requires that InterQual criteria for the relevant Artificial Disc Replacement (Cervical or Lumbar) are met and used to determine clinical medical necessity.

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

Background and Evidence Summary

Artificial disc replacement replaces a degenerated intervertebral disc with a prosthesis intended to preserve range of motion (ROM), maintain spinal curvature, and reduce pain in adults with degenerative disc disease (DDD). The policy distinguishes cervical and lumbar applications with separate medical necessity rules and evidence summaries.

For cervical procedures, coverage is defined for FDA-approved prosthetic intervertebral discs used in skeletally mature individuals with radiculopathy and/or myelopathy at one or two contiguous levels (C3–C7), provided InterQual criteria are met. Cervical TDR after prior cervical fusion may be covered when there is Radiographically Confirmed Complete Arthrodesis at the prior fusion level and other criteria are met. Cervical implant removal or replacement is covered for implant failure. Cervical TDR performed as part of the same surgical plan combined with fusion at another level (Hybrid Cervical Surgery) is considered not medically necessary/unproven.

For lumbar procedures, coverage is limited to use of an FDA-approved prosthetic disc for single-level lumbar degenerative disc disease in skeletally mature individuals with symptomatic, intractable discogenic low back pain attributable to that level and when InterQual lumbar criteria are met. Lumbar TDR combined with existing fusion at another level, performed together with fusion as part of the same plan (Hybrid Lumbar Surgery), or performed at more than one spinal level is considered unproven and not medically necessary due to insufficient evidence.

The policy requires documentation in the patient's medical record to support medical necessity (relevant history, physical exam, and diagnostic test results) and specifies that InterQual clinical criteria are required for determinations. The policy cites multiple evidence reviews (ECRI, Hayes) and RCTs/cohort studies summarized in the supporting evidence showing comparable outcomes to fusion in selected single-level lumbar cases and mixed/limited evidence for multilevel and hybrid constructs.

label	value
InterQual
Required for clinical medical necessity determination (Cervical and Lumbar)
ECRI / Hayes summaries
Multiple evidence reviews cited (ECRI 2021/2025, Hayes 2020-2024) showing single-level lumbar TDR comparable to fusion in select patients; limited evidence for multilevel and hybrid procedures

Contiguous Levels: Vertebral segments adjacent to each other.

Hybrid Cervical Surgery: Combination of an anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA).

Hybrid Lumbar Surgery: Combination of a total disc arthroplasty (TDA) and anterior lumbar interbody fusion (ALIF).

Radiographically Confirmed Complete Arthrodesis: Presence of 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.

Skeletally Mature: Classification when endochondral ossification ceases and the physis 'closes' by becoming totally ossified.