ModifiedUnitedHealthcarePolicy CS121NE.Y

Total Artificial Disc Replacement for the Spine (for Nebraska Only)

Policy governing medical necessity and coverage criteria for cervical and lumbar total artificial disc replacement (TADR/TDA) for members in the state of Nebraska; specifies device, level, and clinical requirements and references InterQual criteria.

Policy Summary

PayerUnitedHealthcare

PolicyTotal Artificial Disc Replacement for the Spine (for Nebraska Only)

Policy CodePolicy CS121NE.Y

Change TypeMaterial revisions to coverage criteria and documentation

Effective DateMar 1, 2026

Next Review Date

Key ActionObtain prior authorization verifying InterQual medical necessity criteria and use of an FDA‑approved prosthetic intervertebral disc.

SourceLink

POLICY UPDATE CHANGES

Revised coverage rationale to specify cervical TADR is proven and medically necessary when all listed conditions are met and InterQual criteria are met, including use of an FDA‑approved prosthetic disc and treatment of only one or two contiguous cervical levels (C3-C7).

Added criteria allowing cervical TADR in individuals with prior cervical fusion when radiographically confirmed complete arthrodesis exists and other criteria are met.

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

Revised lumbar coverage: lumbar TDR is proven and medically necessary only for single-level lumbar degenerative disc disease when InterQual criteria are met; lumbar TDR is unproven/not medically necessary when done with fusion (hybrid), adjacent to existing fusion, or at more than one level.

Added documentation requirements that the patient's medical record must support medical necessity and be made available upon request.

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Coverage Criteria for Total Artificial Disc Replacement

inv-01: Cervical TADR - Initial and repeat

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

Cervical TADR initial criteria: 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).

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

inv-02: Cervical TADR following prior cervical fusion

Cervical total artificial disc replacement after prior cervical spinal fusion is proven and medically necessary when ALL of the following are met and InterQual criteria are met:

Cervical TADR after prior fusion: 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).

Refer to InterQual CP: Procedures, Artificial Disc Replacement, Cervical for detailed clinical criteria; documentation of arthrodesis required.

inv-03: Lumbar TDA - Initial

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

Lumbar TDA initial criteria: 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.

Refer to InterQual Client Defined CP: Procedures, Artificial Disc Replacement, Lumbar (Custom) - UHG for detailed clinical criteria; coverage limited to single-level lumbar TDR.

inv-04: Evidence-based coverage summary

Evidence and clinical outcomes summarized; applicability depends on level-specific evidence and device approvals.

Cervical hybrid surgery: Observational and meta-analysis studies report hybrid cervical constructs may preserve overall cervical ROM, reduce compensatory adjacent-segment ROM, and enable earlier return to work versus ACDF, but evidence is lower-quality without RCTs and long-term outcomes are uncertain.

Hollyer et al. (2020), Zhang et al. (2020) – see policy evidence summaries.

Cervical TDR for adjacent segment disease after prior fusion: Small retrospective and cohort studies report cervical TDR can improve pain and NDI and preserve segmental ROM for symptomatic adjacent-segment disease after prior ACDF; studies limited by small sample sizes and follow-up duration.

Lu et al. and related cohort studies summarized in policy.

Revision/removal of cervical disc arthroplasty: Registry and database series report a low overall revision rate (example: ~2.1% over 10 years in one series); common revisions include anterior cervical fusion ± decompression; osteolysis may be observed and can necessitate removal and fusion when symptomatic.

inv-05: NASS Indications (1-2 level lumbar TDR)

Covered when ALL of the following are met (per NASS 2024 recommendations):

NASS lumbar TDR coverage criteria: 1) Pain arising from 1- or 2-level disc disruption involving L3-4, L4-5, and/or L5-S1; 2) Symptoms present ≥6 months and not responsive to multimodal nonoperative treatment during that period (should include physical therapy/rehabilitation and may include pain management, injections, cognitive behavioral therapy, active exercise); 3) Primary complaint is axial (back) pain, possibly with secondary lower extremity pain; 4) Absence of exclusions such as symptomatic DDD at >2 levels, significant facet arthropathy at index level, spinal instability with spondylolisthesis >Grade I, chronic predominating radiculopathy >1 year, osteopenia with DEXA T-score ≤ -1.0, poorly managed psychiatric disorder, age >60 or <18, infection or tumor.

Per NASS Coverage Policy Recommendation (Feb 2024).

inv-06: Hybrid (TDR + fusion) coverage considerations

Covered with criteria when ALL the following are met:

Hybrid lumbar constructs: 1) Candidate meets selection criteria for each component procedure (TDR levels and fusion level); 2) Rationale documented for the hybrid approach (e.g., multilevel disease with one level appropriate for fusion and adjacent levels appropriate for TDR); 3) Surgeon documents expected benefit and acknowledges limited body of literature; 4) Not performed for ≥3 levels given limited evidence supporting multilevel hybrid constructs.

Evidence supports hybrid constructs for select cases but literature is limited; documentation of rationale required.

inv-07: Cervical TADR - Proven

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

Cervical TADR criteria: 1) An FDA-approved prosthetic intervertebral disc is utilized; 2) Individual diagnosed with only one or two Contiguous Levels of cervical degenerative disc disease (C3-C7); 3) Skeletally mature individual with radiculopathy and/or myelopathy; 4) The arthroplasty will be performed at all symptomatic Contiguous Levels (up to two levels between C3-C7); 5) For two-level contiguous procedures, the device must be FDA-approved for two levels (and when a prior TADR exists, the second device must be FDA-approved for two-level use).

InterQual CP: Procedures, Artificial Disc Replacement, Cervical referenced for clinical detail.

inv-08: Cervical TADR after prior fusion - Proven

Cervical total artificial disc replacement after prior cervical spinal fusion is proven and medically necessary when ALL of the following are present and InterQual criteria are met:

Cervical TADR after fusion: 1) An FDA-approved prosthetic intervertebral disc is utilized; 2) Treating individuals with only one level or two Contiguous Levels of cervical degenerative disc disease (C3-C7); 3) Skeletally mature individual with radiculopathy and/or myelopathy; 4) The arthroplasty will be performed at all symptomatic Contiguous Levels (up to two levels between C3-C7); 5) Radiographically Confirmed Complete Arthrodesis of a previous cervical spinal fusion at another level (adjacent or non-adjacent).

Radiographic confirmation of complete arthrodesis required (see fusion confirmation documentation; motion cutoff <1 mm between spinous processes on flexion-extension radiographs may be used).

inv-09: Cervical TADR - Not Medically Necessary

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

Cervical NMN: 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).

Policy states hybrid cervical surgery is unproven and not medically necessary.

inv-10: Lumbar TDR - Proven

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

Lumbar TDR criteria - proven: 1) An FDA-approved prosthetic intervertebral disc is utilized; 2) Treating individuals with only a single level of lumbar degenerative disc disease; 3) Skeletally mature individual; 4) Symptomatic intractable discogenic low back pain attributable to that level.

Refer to InterQual Client Defined CP: Procedures, Artificial Disc Replacement, Lumbar (Custom) - UHG for detailed clinical criteria; policy limits coverage to single-level lumbar TDR.

inv-11: Lumbar TDR - Not Medically Necessary

Lumbar total artificial disc replacement is unproven and not medically necessary when ANY of the following apply:

Lumbar NMN list: 1) Performed at one level combined with an existing lumbar spinal fusion surgery at another level (adjacent or non-adjacent); 2) Performed with lumbar spinal fusion surgery as part of the same surgical plan (Hybrid Lumbar Surgery); 3) Performed at more than one spinal level.

Policy and evidence reviews identify insufficient support for multilevel and hybrid lumbar TDR procedures.

inv-12: Cervical disc removal or replacement - Proven

Cervical artificial disc removal or replacement with an FDA-approved (one or two-level) prosthetic intervertebral disc is proven and medically necessary in individuals with implant failure after prior disc replacement when ALL of the following are met:

Cervical removal/replacement: Implant failure after prior disc replacement requiring removal or replacement; Use of an FDA-approved prosthetic intervertebral disc for the indicated number of levels (one or two, as applicable).

Policy references InterQual and device approval status; device must be FDA-approved for the intended number of levels.

Cervical or lumbar total artificial disc replacement (TADR/TDA) performed at one spinal level combined with spinal fusion at another level as part of the same operative plan (a hybrid procedure) is identified in this policy as a distinct clinical scenario. The policy treats hybrid procedures separately from single‑modality arthroplasty or fusion because the combined approach changes the intended biomechanical construct and is not supported by the same evidence base as isolated disc replacement or fusion. As a result, hybrid procedures are addressed explicitly in the exclusions and not‑medically‑necessary sections and may be denied when submitted as a single surgical plan.

Available evidence for multilevel lumbar total disc replacement is limited and of low to moderate quality, with small sample sizes, nonrandomized designs, short or incomplete long‑term follow‑up, and risk of bias. Systematic and evolving evidence reviews (Hayes, ECRI) conclude there is minimal or unclear support for routine use of two‑level or multilevel lumbar TDR; therefore coverage for multilevel lumbar TDR is restricted because current data do not reliably demonstrate long‑term safety or effectiveness compared with alternative treatments.

The policy incorporates NASS (2024) recommendations for lumbar disc arthroplasty: lumbar disc replacement is not indicated when the case fails to meet all NASS selection criteria (for example, symptomatic degenerative disc disease at >2 levels, significant facet arthropathy at the index level, spinal instability with spondylolisthesis > Grade I, predominant chronic radiculopathy >1 year, osteopenia with DEXA T‑score ≤ -1.0, age outside 18–60 years, infection or tumor). Procedures that do not satisfy these NASS criteria are considered outside the indicated use and pose a coverage risk.

Cervical total artificial disc replacement combined with cervical fusion in the same surgical plan (hybrid cervical surgery) is explicitly designated as unproven and not medically necessary in this policy. Submissions for a hybrid cervical approach should be expected to follow the non‑coverage pathway unless compelling, device‑specific, high‑quality evidence is provided to justify an exception.

The policy reiterates that lumbar total disc replacement performed at more than one spinal level, performed in combination with fusion during the same surgical plan (a hybrid lumbar procedure), or performed at one level adjacent to an existing lumbar fusion is considered unproven and not medically necessary because of insufficient evidence of efficacy and safety for these scenarios.

Hybrid procedures—defined here as combinations of disc arthroplasty at some levels and fusion (ACDF or ALIF) at other levels performed as part of the same operative plan—are treated as separate from isolated TDR or isolated fusion. The policy language is intentionally repetitive across sections to ensure clarity: hybrid cervical and hybrid lumbar constructs lack the same level of evidence as single‑level arthroplasty and are therefore generally considered not medically necessary unless exceptional supporting evidence is documented.

High‑quality, long‑term evidence for multilevel (two‑level or greater) lumbar total disc replacement is lacking. Reviews highlight the need for larger, well‑designed randomized trials with long‑term follow‑up to evaluate safety and durability; until such data are available, multilevel lumbar TDR remains unsupported for routine coverage.

For informational context, the 2020 NICE guideline on low back pain and sciatica recommends that physicians do not offer disc replacement for people with low back pain; this guidance is included as a referenced position but does not by itself determine coverage decisions in this policy.

To remove any ambiguity in coverage status, the policy clarifies that hybrid cervical surgery—cervical TADR performed at one level combined with cervical fusion at another level during the same surgical plan—is considered not medically necessary and is excluded from coverage under the stated criteria.

Similarly, the policy clarifies that multi‑level lumbar TDR or hybrid lumbar TDR+fusion performed as part of the same surgical plan is considered not medically necessary. This reflects the limited and low‑quality evidence for multilevel and hybrid lumbar constructs and aligns with the policy’s exclusions and prior‑authorization review expectations.

Procedure and Study Coding

Applicable procedure CPT/HCPCS codesCPT | HCPCS

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

Coding used in studiesmixed

CPT	CPT and ICD-9/10 coding was utilized in the database study to identify primary ACDA and revision/removal procedures (exact codes not listed in this excerpt).

inv-25: fusion motion cutoff

Fusion motion cutoff< 1 mm movement between spinous processes on lateral flexion–extension radiographs when confirming arthrodesis

Imaging modalitiesPlain radiographs (flexion–extension) and CT may be used to evaluate bridging trabecular bone and lucency

Purpose of cutoffObjective, reproducible criterion recommended in literature to confirm radiographic fusion prior to considering subsequent arthroplasty

Prior Authorization, Documentation, and Provider Requirements

Prior Authorization

Prior Authorization Required: Indication and Device Evidence

Prior authorization is required to verify the indication for artificial disc replacement and that device-specific evidence and approvals are met before scheduling. Requests will be evaluated against InterQual criteria and device labeling.

Prior authorization must confirm use of an FDA‑approved prosthetic intervertebral disc for the intended spinal level(s).
For two-level cervical TADR, the device must be FDA‑approved for two-level use (including when a prior cervical TADR was previously performed).
For lumbar TDR, prior authorization must verify device-specific randomized controlled trial (RCT) evidence and that the device is indicated for the requested level (single-level lumbar TDR is the established indication).

Prior Authorization

Prior Authorization Required: Lumbar TDR

Prior authorization must be obtained for lumbar total disc replacement (TDR) to confirm patient selection and documentation. Lumbar TDR is covered only when all clinical selection criteria and InterQual (Client Defined) criteria are met.

Background and Evidence Summary

Total artificial disc replacement replaces a degenerating intervertebral disc to preserve or restore range of motion and reduce pain in adults with degenerative disc disease. Cervical TADR is considered when an FDA‑approved prosthetic disc is used to treat symptomatic disease at one or two contiguous cervical levels (C3–C7), in a skeletally mature individual with radiculopathy and/or myelopathy. Lumbar TDR is considered for symptomatic, intractable discogenic low back pain attributable to a single lumbar level when InterQual selection criteria are met.

Definitions and Key Terms

inv-44: Contiguous Levels — definition

DefinitionVertebral segments adjacent to each other

Policy usageUsed to limit cervical TADR coverage to one or two contiguous levels (C3–C7)

Source noteReferenced definition added to policy; see federal/state definitions that may supersede

inv-45: Hybrid Cervical Surgery — definition

DefinitionCombination of anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA)

Policy positionHybrid Cervical Surgery (arthroplasty plus fusion in the same surgical plan) is unproven and not medically necessary in this policy when performed as part of the same operation

Policy Revision History

2026-03-01policy_revisionLatest

Revised coverage rationale: clarified cervical TADR is proven and medically necessary when InterQual criteria are met and limited to one or two contiguous cervical levels (C3-C7); added pathway allowing cervical TADR after prior cervical fusion when radiographically confirmed complete arthrodesis is present; specified device-level FDA approvals for two-level cervical TADR; updated documentation requirements; removed a reference link to a Nebraska-only medical policy.

2026-03-01policy_revision

Updated lumbar coverage: specified lumbar TDR is proven and medically necessary only for a single symptomatic lumbar level when InterQual criteria are met and stated lumbar TDR is unproven/not medically necessary when performed as a hybrid with fusion, adjacent to an existing fusion, or at more than one level.

Policy Summary

PayerUnitedHealthcare

PolicyTotal Artificial Disc Replacement for the Spine (for Nebraska Only)

Policy CodePolicy CS121NE.Y

Change TypeMaterial revisions to coverage criteria and documentation

Effective DateMar 1, 2026

Next Review Date

Key ActionObtain prior authorization verifying InterQual medical necessity criteria and use of an FDA‑approved prosthetic intervertebral disc.

SourceLink

On This Page

Denial Risk

Denial Risk: Coverage Criteria Not Met

Coverage is at risk and requests may be denied if the patient does not meet established selection criteria or if key supporting documentation is absent.

Examples of exclusionary clinical features that may trigger denial: significant facet arthropathy at the index level, spondylolisthesis > Grade I, symptomatic degenerative disc disease at >2 levels, chronic radiculopathy with predominant leg pain >1 year, osteopenia (DEXA T-score ≤ -1.0), age >60 or <18, active infection or tumor, or poorly managed psychiatric disorder.
Requests for hybrid surgeries (cervical or lumbar TADR combined with fusion in the same surgical plan), multi-level lumbar TDR, or TDR adjacent to an existing fusion will be evaluated as not medically necessary and are likely to be denied.
Insufficient long-term device-specific evidence or lack of RCTs for the specific device/indication may also lead to denial.

Documentation Required

Documentation Required: Fusion Confirmation

When prior cervical fusion is claimed to be radiographically solid before performing a TADR at another level, documentation confirming complete arthrodesis must be provided.

Radiographic confirmation may include plain radiographs (flexion/extension) and/or CT imaging as appropriate.
Objective criterion recommended: < 1 mm of movement between spinous processes on lateral flexion–extension radiographs to support confirmed fusion.
Provide the imaging reports and, if available, comparative studies demonstrating absence of motion at the fused segment; reviewers may request images for re-evaluation.

Documentation Required

Documentation Requirement: Medical Record and Clinical Evidence

The patient's medical record must fully support medical necessity for authorization. Complete, legible documentation should be submitted with the prior authorization request to avoid delays or denials.

Required clinical documentation includes: site(s) of pathology, duration of symptoms (≥ 6 months when applicable for lumbar), documentation of failure of multimodal nonoperative treatment, physical exam findings correlating to imaging, and device-specific indications/contraindications.
Include operative reports for prior spine surgeries, imaging reports (MRI/CT/X‑ray), DEXA results if bone quality is a concern, and documentation of psychosocial/psychiatric optimization when relevant.
Make full medical records available upon request; omission of essential information may result in denial of the request.

inv-49: Hybrid Surgery (HS) — alternate definition / usage in evidence

Definition / alternate usageHybrid Surgery (HS): combination of TDR (arthroplasty) at some levels and fusion (ACDF or ALIF) at other levels to treat multilevel degenerative disc disease

Evidence interpretationIn cervical HS, observational studies report preserved overall ROM and earlier return to work versus ACDF, but evidence lacks RCTs and long-term outcomes are uncertain

Policy implicationAlthough HS is described in evidence, the policy treats hybrid procedures as unproven/not medically necessary when performed as part of the same surgical plan in specified contexts

inv-53: Hybrid Cervical Surgery / Hybrid Lumbar Surgery — defined terms added and policy position on hybrid procedures

Defined termsHybrid Cervical Surgery and Hybrid Lumbar Surgery defined as arthroplasty combined with fusion as part of the same surgical plan

Policy positionPolicy specifies hybrid cervical or lumbar surgeries performed as part of the same operation are unproven and not medically necessary in defined circumstances

ApplicationProviders should not expect coverage when TADR is performed with fusion in the same surgical plan unless exceptional documentation and alignment with criteria are provided

inv-54: Radiographically Confirmed Complete Arthrodesis — documentation requirement term used for cervical TADR after fusion

DefinitionRadiographically 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

Documentation requirementRequired documentation to permit cervical TADR after prior cervical fusion; may require plain radiographs or CT to demonstrate criteria

Objective measureRelative motion of spinous processes recommended as an objective and reproducible assessment