Total Artificial Disc Replacement Spine Nj Cs
Defines medical necessity criteria, limits, and exclusions for cervical and lumbar total artificial disc replacement (TADR/TDR) for UnitedHealthcare members in New Jersey, including requirements for FDA-approved devices and references to InterQual clinical criteria; includes related coding and clinical evidence summaries.
Revised cervical criteria to state cervical total artificial disc replacement is proven and medically necessary when all listed criteria and InterQual criteria are met, including device FDA-approval, symptomatic one- or two-contiguous level disease (C3-C7), skeletally mature with radiculopathy/myelopathy, and arthroplasty performed at all symptomatic contiguous levels.
Clarified cervical TADR is proven and medically necessary for individuals with prior cervical spinal fusion when all listed criteria and InterQual criteria are met, including radiographically confirmed complete arthrodesis of previous fusion at another level.
Revised lumbar criteria to state lumbar total artificial disc replacement is proven and medically necessary only for single-level lumbar degenerative disc disease when InterQual Client Defined criteria are met and an FDA-approved device is utilized.
Added language that cervical artificial disc removal or replacement is medically necessary for implant failure after prior disc replacement.
Clarified that cervical TADR combined with fusion at another level as part of the same surgical plan (hybrid surgery) is unproven and not medically necessary.
Added definitions for Contiguous Levels, Hybrid Cervical Surgery, Hybrid Lumbar Surgery, and Radiographically Confirmed Complete Arthrodesis; updated definition of 'Skeletally Mature'.
Added/clarified that medical records documentation may be required to assess whether the member meets criteria and must include history, physical exam, diagnostic results, and documentation of device FDA-approval status when applicable.
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