CurrentUnitedHealthcarePolicy CS121OH.C

Total Artificial Disc Replacement for the Spine (Ohio only)

Clinical coverage policy describing medical necessity and investigational determinations for cervical and lumbar total artificial disc replacement (TDR) applicable only to UnitedHealthcare members in the state of Ohio.

Policy Summary

PayerUnitedHealthcare

PolicyTotal Artificial Disc Replacement for the Spine (Ohio only)

Policy CodePolicy CS121OH.C

Change TypeCoverage clarification & limitations

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionProvide complete, legible medical records (history, exam, diagnostics) to document medical necessity for review.

SourceLink

POLICY UPDATE CHANGES

Replaced language that previously stated cervical artificial disc replacement is proven and medically necessary for certain patients with language clarifying that cervical artificial disc removal or replacement is proven and medically necessary for implant failure after prior disc replacement.

Changed cervical hybrid surgery language to state cervical total artificial disc replacement is unproven and not medically necessary when performed at one level combined with cervical spinal fusion at another level as part of the same surgical plan.

Added language indicating lumbar total artificial disc replacement is unproven and not medically necessary when combined with an existing lumbar spinal fusion at another level (adjacent or non-adjacent) or when performed with fusion as part of the same surgical plan (hybrid lumbar surgery).

Added requirements and clarifications regarding medical records documentation and that coverage is determined by federal, state, contractual requirements and applicable laws.

Added language stating benefit coverage is determined by federal, state, or contractual requirements and applicable laws, and that medical records documentation may be required to assess clinical criteria but does not guarantee coverage.

Updated definition of 'Skeletally Mature' and updated Clinical Evidence and References sections; archived previous policy version CS121OH.B.

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Coverage and Medical Necessity Criteria

Cervical

Coverage and medical necessity reference:

ALL of the following

- Specific cervical determinations in this policy
  - 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.
  - Cervical total artificial disc replacement is unproven and not medically necessary when 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

Coverage and medical necessity reference:

ALL of the following

- Lumbar determinations in this policy
  - Lumbar total artificial disc replacement is unproven and not medically necessary due to insufficient evidence of efficacy when performed at one level combined with an existing lumbar spinal fusion surgery at another level (adjacent or nonadjacent).
  - Lumbar total artificial disc replacement is unproven and not medically necessary when performed with lumbar spinal fusion surgery as part of the same surgical plan (hybrid lumbar surgery).
  - Lumbar total artificial disc replacement is unproven and not medically necessary when performed at more than one spinal level.

Lumbar total disc replacement — coverage stance

Policy-level determinations based on evidence summarized in this section (Part 2):

ALL of the following

Lumbar total artificial disc replacement (TDR) is considered unproven and not medically necessary when performed at one level combined with an existing lumbar spinal fusion at another level (adjacent or non-adjacent).
Lumbar TDR is unproven and not medically necessary when performed with lumbar spinal fusion surgery as part of the same surgical plan (hybrid lumbar surgery).

Cervical total disc replacement — coverage stance revisions

Policy-level determinations summarized in the revision history:

ALL of the following

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.
Cervical total artificial disc replacement is unproven and not medically necessary when 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).

NASS listed contraindications / scenarios where lumbar disc arthroplasty is NOT indicated

Lumbar disc arthroplasty is not indicated for any case with ANY of the following:

ANY of the following

Degenerative disc disease at more than two levels.
Significant facet arthropathy at the index level or pain primarily facet-mediated.
Spinal instability with spondylolisthesis greater than Grade I.
Chronic radiculopathy with predominance of leg pain > back pain extending ≥ 1 year.
Osteopenia as evidenced by a DEXA bone mineral density T-score less than or equal to -1.0.

Coverage assessment and medical necessity determination actions

ALL of the following

Benefit coverage for health services is determined by federal, state, or contractual requirements and applicable laws which may require coverage for a specific service.
Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage.
Medical records documentation does not guarantee coverage of the service requested.
The patient's medical record must contain documentation that fully supports the medical necessity for the requested services.

Documentation and Medical Records

Requirements for review and medical necessity determination:

ALL of the following

Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage and must fully support medical necessity (relevant history, physical exam, diagnostic tests/procedures).
Documentation must be legible, maintained in the patient record, and made available upon request.
For services stated as unproven or with coverage/quantity limits, evaluation will use Ohio Administrative Code 5160-101.

Documentation requirement

ALL of the following

The patient's medical record must contain documentation that fully supports the medical necessity for the requested services.
Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the service requested.

Documentation requirement

ALL of the following

Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage.
The patient's medical record must contain documentation that fully supports the medical necessity for the requested services.
Documentation includes but is not limited to relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Documentation supporting medical necessity should be legible, maintained in the patient's medical record, and must be made available upon request.

Guideline-based selection criteria referenced (NASS summary)

ALL of the following

Pain arising from 1- or 2-level disc disruption involving L3-4, L4-5, and/or L5-S1 segments.
NASS August 2024 recommendations summarized
Presence of symptoms for at least six months or greater and not responsive to multi-modal nonoperative treatment during that period (including, but not limited to, physical therapy/rehabilitation; may include pain management, injections, CBT, active exercise).
Primary complaint of axial (back) pain, with possible secondary complaint of lower extremity pain.

Procedure Codes

Applicable Procedure CodesCPT

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; second level, cervical (List separately in addition to code for primary procedure)
22860	Total disc arthroplasty (artificial disc), anterior approach; 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

Codes in document text (none explicitly listed in Part 2)mixed

No codes listed

Provider Requirements and Prior Authorization Notes

Documentation Required

Provide supporting medical records for medical necessity review

Providers must supply relevant medical history, physical examination findings, and diagnostic test results to support that the member meets InterQual (or policy) criteria; records must be legible and available upon request.

Affected procedure codes: 0098T, 0165T, 22856, 22857, 22858, 22860, 22861, 22862, 22899

Documentation Required

Ohio administrative rule evaluation for unproven/limited services

Requests for services stated as unproven or subject to coverage/quantity limits will be evaluated for medical necessity using Ohio Administrative Code 5160-101; providers should be prepared to document applicability of the OAC to the request.

Documentation Required

Medical record documentation required

Clinical and Policy Background

Artificial total disc replacement (also called total disc arthroplasty or TDR/TDA) involves replacing a degenerated intervertebral disc with a prosthetic device intended to preserve range of motion (ROM) at the index level and reduce pain in adults with degenerative disc disease. These prostheses replace the degenerated disc and have been proposed to improve flexibility, maintain spinal curvature, and provide an equalized weightbearing surface while reducing pain (description of services).

Policy conclusions and guidance differ by spinal region. For the cervical spine, the policy recognizes that removal or replacement of a cervical artificial intervertebral disc with an FDA‑approved one- or two-level prosthesis is proven and medically necessary when performed for implant failure after prior disc replacement (cervical determinations). Multiple studies and reviews of revision surgery after cervical disc arthroplasty report that reoperation for failed cervical devices is uncommon and that revision procedures (including replacement or conversion to fusion) can produce improved clinical outcomes in selected patients, supporting the policy position for revision in implant failure scenarios.

By contrast, evidence and guideline support for lumbar TDR are more limited and selective. The policy states that lumbar TDR is unproven and not medically necessary in certain settings because of insufficient evidence of efficacy when performed as part of hybrid constructs or across multiple levels. Specifically, lumbar TDR is considered unproven/not medically necessary when: (1) done at one level combined with an existing lumbar fusion at another level (adjacent or nonadjacent); (2) performed concurrently with lumbar spinal fusion as part of the same surgical plan (hybrid lumbar surgery); or (3) performed at more than one spinal level. Systematic reviews and evolving evidence assessments (Hayes, ECRI) and RCTs for single‑level devices inform these cautious determinations.

Operationally, the policy directs use of InterQual clinical coverage criteria for detailed medical necessity thresholds and emphasizes that medical records documentation must fully support the requested service; documentation (history, exam, diagnostics) may be requested during review but does not guarantee coverage. The revision history clarifies that the change for cervical cases focuses on coverage of revision/replacement for implant failure rather than endorsing primary use in broader prior‑fusion scenarios, and adds explicit language restricting hybrid procedures in both cervical and lumbar regions as unproven/not medically necessary in the specified circumstances.

Key Definitions

Definitions

Skeletally MatureThe classification of bone when endochondral ossification ceases and the physis 'closes' by becoming totally ossified (Reith, 2018).

Hybrid surgery (HC)Surgical construct combining total disc arthroplasty (TDR) at one or more levels with anterior lumbar interbody fusion (ALIF) or other fusion at another level, performed concurrently or as part of the same surgical plan.

TDR / TDATotal disc replacement / total disc arthroplasty — prosthetic intervertebral disc implantation intended to preserve motion at the index level.

Medical records documentationClinical notes, test results, imaging, and other records in the patient file that demonstrate the member meets clinical criteria and medical necessity for services.

Skeletally Mature (updated note)Updated definition referenced in the revision history (specific definition text present elsewhere in the full policy).

Numeric and Clinical Thresholds

Key Thresholds / Exclusions

Nonoperative treatment duration (NASS criterion)>= 6 months of multimodal nonoperative management (NASS requirement for lumbar TDR candidates).

Age limits (NASS contraindication)Age 18 to 60 years (NASS: not indicated if <18 or >60).

Bone density exclusionDEXA T-score <= -1.0 (osteopenia threshold listed as exclusion by NASS).

Policy Changes and Rationale

2026-03-01revision (material)Latest

Clarified coverage to state cervical artificial disc removal or replacement is proven and medically necessary for implant failure after prior disc replacement (replacing prior language about primary cases associated with prior fusion).

2026-03-01revision (material)

Total Artificial Disc Replacement for the Spine (Ohio only)

Coverage and Medical Necessity Criteria

Procedure Codes

Provider Requirements and Prior Authorization Notes

Clinical and Policy Background

Key Definitions

Numeric and Clinical Thresholds

Policies to Review Alongside This One

Policy Changes and Rationale