UnitedHealthcare Total Disc Replacement Coverage Update

Coverage Criteria for Cervical and Lumbar Total Artificial Disc Replacement

inv-01: Cervical: Medically Necessary

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

Cervical TADR general criteria: An FDA-approved prosthetic intervertebral disc is utilized

InterQual CP: Procedures, Artificial Disc Replacement, Cervical referenced

Cervical levels: Individual diagnosed with only one or two Contiguous Levels of cervical degenerative disc disease (C3-C7)one or two contiguous levels (C3-C7)

Skeletal maturity and symptoms: Skeletally mature individual with radiculopathy and/or myelopathy

Treatment extent: Arthroplasty will be performed at all symptomatic Contiguous Levels (up to two levels between C3-C7); for two-level procedures, device must be FDA-approved for two levels

If a prior cervical TADR was performed, the second contiguous level device must be FDA-approved for two levels

inv-02: Cervical post-fusion: Medically Necessary

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

Device requirement: An FDA-approved prosthetic intervertebral disc is utilized

InterQual CP: Procedures, Artificial Disc Replacement, Cervical referenced

Levels treated: Treating individuals with only one level or two Contiguous Levels of cervical degenerative disc disease (C3-C7)one or two contiguous levels (C3-C7)

Skeletal maturity and symptoms: Skeletally mature individual with radiculopathy and/or myelopathy

Treatment extent: Arthroplasty performed at all symptomatic Contiguous Levels (up to two levels between C3-C7)

inv-03: Lumbar: Medically Necessary

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

Lumbar TDA general criteria: An FDA-approved prosthetic intervertebral disc is utilized

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

Levels treated: Treating individuals with only a single level of lumbar degenerative disc diseasesingle level

Skeletal maturity: Skeletally mature individual

Symptom attribution: Symptomatic intractable discogenic low back pain attributable to that level

inv-04: Unproven / Not Medically Necessary

Situations considered unproven and not medically necessary:

Hybrid Cervical: Cervical total artificial disc replacement performed at one level combined with cervical spinal fusion surgery at another level as part of the same surgical plan (Hybrid Cervical Surgery)

Explicitly stated as unproven and not medically necessary

Lumbar TADR with existing fusion: Lumbar total artificial disc replacement performed at one level combined with an existing lumbar spinal fusion surgery at another level (adjacent or non-adjacent)

Explicitly stated as unproven and not medically necessary

Hybrid Lumbar: Lumbar total artificial disc replacement performed with lumbar spinal fusion surgery as part of the same surgical plan (Hybrid Lumbar Surgery)

Explicitly stated as unproven and not medically necessary

inv-05: Revisions: Medically Necessary

Revisions and removals:

Cervical revision/removal: 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.

inv-06: Cervical HS / CADR — evidence summary

Evidence-based observations relevant to cervical hybrid surgery and CADR:

Outcomes and evidence: Observational studies and meta-analyses report improved NDI and VAS scores after cervical hybrid surgery and CADR; hybrid procedures tend to better preserve overall cervical range of motion and may reduce adjacent-segment ROM increases seen with multilevel ACDF.

Most studies are nonrandomized or retrospective with limited long-term follow-up.

inv-07: CADR for ASD after prior ACDF

Evidence and findings for CADR used to treat adjacent segment disease after prior fusion:

ASD revision outcomes: Systematic reviews and small retrospective studies report that TDR/CTDR can provide similar or better range-of-motion preservation and comparable clinical outcomes versus ACDF when performed for adjacent segment disease after prior fusion; available data are from small cohorts with short- to mid-term follow-up.

Longer-term comparative data are limited.

inv-08: Cervical ACDA revision/replacement

Revision indications, outcomes, and evidence:

Revision indications and outcomes: Revision indications include spondylosis, mechanical complications, osteolysis, malposition, subsidence, infection, and insufficient decompression; removal and conversion to fusion is common and reported revision rates in one database series were approximately 2.1% over the study window.

Evidence largely from retrospective series and small studies.

inv-09: Lumbar TDR and hybrid constructs — coverage-relevant evidence

Coverage-relevant evidence and limitations for lumbar TDR and hybrid constructs:

Single-level lumbar TDR evidence: Randomized trials and comparative reviews provide moderate-quality evidence that single-level lumbar TDR can be comparable to fusion in properly selected patients who have failed >= 6 months of nonsurgical care.failed >= 6 months of conservative management

Longer-term durability findings are mixed and selection criteria are important.

Multilevel/hybrid lumbar evidence: Systematic reviews and evolving evidence assessments report minimal or unclear support for two-level or hybrid lumbar TDR; studies are limited by small size, nonrandomized designs, and lack of long-term outcomes.

Insufficient evidence to conclude superiority or broad applicability.

inv-10: NASS indication criteria (lumbar TDR)

Covered when ALL of the following are met:

NASS lumbar TDR indication criteria: Pain arising from 1- or 2-level disc disruption involving L3-4, L4-5, and/or L5-S1 segments; symptoms present for at least six months and not responsive to multimodal nonoperative treatment (including physical therapy/rehabilitation and optionally pain management, injections, CBT, exercise); primary complaint of axial pain (possible secondary lower extremity pain)>= 6 months of symptoms and nonresponsive to multimodal nonoperative care

From NASS 2024 coverage recommendation

inv-11: NASS exclusion/contraindications

Not indicated if ANY of the following are present:

NASS lumbar TDR exclusion criteria: Disease at >2 levels; significant facet arthropathy at index level or pain primarily facet-mediated; spinal instability with spondylolisthesis > Grade I; chronic radiculopathy with predominant leg pain >1 year; osteopenia with DEXA T-score <= -1.0; poorly managed psychiatric disorder; age >60 or <18; infection or tumor

From NASS 2024 coverage recommendation

inv-12: Cervical total artificial disc replacement — medically necessary

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

Cervical TADR coverage: An FDA-approved prosthetic intervertebral disc is utilized

InterQual CP: Procedures, Artificial Disc Replacement, Cervical referenced

Levels treated: Individual has only one or two contiguous levels of cervical degenerative disc disease (C3-C7)one or two contiguous levels (C3-C7)

Skeletal maturity and symptoms: Skeletally mature individual with radiculopathy and/or myelopathy

Treatment extent: Arthroplasty will be performed at all symptomatic contiguous levels (up to two levels between C3-C7)

inv-13: Cervical TADR in patients with prior cervical fusion — medically necessary

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

Device requirement: An FDA-approved prosthetic intervertebral disc is utilized

InterQual CP: Procedures, Artificial Disc Replacement, Cervical referenced

Levels treated: Treating individuals with only one level or two Contiguous Levels of cervical degenerative disc disease (C3-C7)one or two contiguous levels (C3-C7)

Skeletal maturity and symptoms: Skeletally mature individual with radiculopathy and/or myelopathy

Treatment extent: Arthroplasty performed at all symptomatic Contiguous Levels (up to two levels between C3-C7)

inv-14: Cervical TADR — not medically necessary

Not medically necessary - Cervical: Cervical TADR performed at one level combined with cervical spinal fusion at another level (adjacent or non-adjacent) as part of the same surgical plan (Hybrid Cervical Surgery)

Policy states this is unproven and not medically necessary

inv-15: Lumbar total artificial disc replacement — medically necessary

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

Lumbar TADR coverage: An FDA-approved prosthetic intervertebral disc is utilized

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

Levels treated: Treating individuals with only a single level of lumbar degenerative disc diseasesingle level

Skeletal maturity: Skeletally mature individual

Symptom attribution: Symptomatic intractable discogenic low back pain attributable to that level

inv-16: Lumbar TADR — not medically necessary

Not medically necessary - Lumbar: Lumbar TADR performed at one level combined with an existing lumbar spinal fusion at another level (adjacent or non-adjacent); lumbar TADR performed with lumbar spinal fusion as part of the same surgical plan (Hybrid Lumbar Surgery); lumbar TADR performed at more than one spinal level

Policy states these are unproven and not medically necessary due to insufficient evidence of efficacy

Cervical one-level total artificial disc replacement performed in combination with a cervical fusion at a different level in the same surgical plan (Hybrid Cervical Surgery) is considered unproven and not medically necessary. The policy explicitly states these hybrid cervical constructs are excluded from coverage and may be denied when submitted as part of the same operative plan.

Published clinical evidence is insufficient to support routine use of multilevel lumbar total disc replacement. Multiple evidence reviews and analyses note small study sizes, nonrandomized designs, short follow-up, loss to follow-up, and lack of long-term durability data for two-level or multilevel lumbar TDR. Because of these limitations the policy deems multilevel lumbar TDR indications unproven and not medically necessary pending larger, well-designed studies.

Requests for lumbar disc arthroplasty that do not meet established selection criteria per NASS are not indicated. NASS guidance specifies exclusions including disease at >2 levels, significant facet arthropathy at the index level, spinal instability (spondylolisthesis > Grade I), predominant chronic radiculopathy (>1 year), osteopenia (DEXA T-score ≤ -1.0), age outside the recommended range (<18 or >60 years), poorly managed psychiatric disorder, infection, or tumor. In addition, lumbar TDR studies generally require failure of multimodal nonoperative care for at least 6 months prior to consideration.

The policy specifically states that combining cervical total artificial disc replacement with fusion during the same operative plan (hybrid cervical surgery) is unproven and not medically necessary. Such combined procedures are excluded and may be denied when submitted as a single surgical plan.

Lumbar total artificial disc replacement performed in combination with fusion in the same surgical plan (Hybrid Lumbar Surgery), performed at more than one spinal level, or performed at one level in a patient with an existing lumbar fusion at another level (adjacent or non-adjacent) is considered unproven and not medically necessary and may be denied due to insufficient evidence of efficacy.

In summary, the policy disallows hybrid procedures in the cervical spine (one-level TADR plus fusion at another level in the same plan) and likewise considers hybrid lumbar procedures and multilevel lumbar TDR (>1 level) to be unproven and not medically necessary. Cervical single- or two-level TADR and single-level lumbar TDR remain the covered positions when their specific criteria are met; hybrid and multilevel constructs do not meet those evidentiary or coverage standards.

There is limited and evolving support for two-level or multilevel lumbar TDR and for hybrid lumbar constructs in the literature. Systematic reviews and evidence summaries report similar short- to mid-term patient-reported outcomes between two-level or hybrid TDR constructs and fusion, but studies are small, often nonrandomized or retrospective, and lack long-term follow-up; therefore the policy treats these indications as unproven and not medically necessary until stronger evidence becomes available.

External guidance and evidence reviews inform the policy: the American Pain Society (2009) concluded there is insufficient evidence to evaluate long-term benefits and harms of disc replacement, and NICE (2020) recommends not offering disc replacement for low back pain. More recent evidence reviews (ECRI, Hayes) similarly identify minimal or unclear support for multilevel or hybrid lumbar constructs and call for larger, high-quality, long-term studies.

Accordingly, the policy reiterates that hybrid cervical procedures (TADR plus fusion in the same surgical plan), hybrid lumbar procedures, and multilevel lumbar TDR (>1 level) are considered unproven and not medically necessary and are excluded from coverage until sufficient, higher-quality evidence demonstrates safety and long-term effectiveness.

Procedure and Reference Codes

Applicable Procedure CPT/HCPCS Codesmixed

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.

Codes referenced in studiesmixed

CPT and ICD codes referenced in study but not listed in this excerpt

Studies used CPT and ICD-9/10 coding to identify cases and revisions; exact codes not present in this document segment.

Interspinous motion cutoff for fusion — key measurement (< 1 mm movement)

Interspinous motion cutoff< 1 mm movement between spinous processes on lateral flexion-extension radiographs

Measurement methodAssess relative motion of spinous processes on lateral flexion-extension radiographs

PurposeUsed as objective radiographic criterion when confirming fusion/arthrodesis

Conservative management duration prior to TDR — key requirement (>= 6 months)

Minimum duration>= 6 months of nonoperative multimodal conservative management (physical therapy/rehabilitation, may include pain management/injections/Cognitive Behavioral Therapy)

Evidence basis

Provider Actions, Prior Authorization, and Documentation Requirements

Prior Authorization

Prior Authorization Required for Multilevel or Hybrid Lumbar TDR

Prior authorization is required for requests involving lumbar multilevel total disc replacement (TDR) or hybrid TDR constructs (TDR combined with fusion), as these are subject to additional clinical review and often are not considered medically necessary due to limited supporting evidence.

Prior authorization required and linked to specific procedure codes (see Applicable Codes).
Requests for lumbar TDR performed at more than one level, hybrid lumbar constructs, or lumbar TDR with an existing fusion at another level are likely to be denied or require enhanced clinical justification.

Note

InterQual Criteria Applied During Prior Authorization

Coverage determinations reference InterQual criteria during prior authorization and medical necessity review. For cervical and lumbar TDR, the applicable InterQual (or client-defined InterQual) CP must be satisfied in addition to policy criteria.

Click the InterQual link in the policy for CP: Procedures, Artificial Disc Replacement, Cervical and the Client Defined CP: Procedures, Artificial Disc Replacement, Lumbar (Custom) - UHG.

Definitions and Key Terms

Contiguous Levels — definition

DefinitionVertebral segments adjacent to each other

Policy useUsed to specify which levels count as contiguous when determining eligibility for multilevel procedures

Source citationTanasansomboon, 2023 (policy definitions)

Hybrid Cervical Surgery — definition

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

Alternate phrasingAlso described as procedures combining TADR with fusion in the cervical spine as part of the same surgical plan

Background and Evidence Context

Artificial total disc replacement is a surgical option intended to replace a degenerating intervertebral disc to preserve segmental range of motion and reduce pain in adults with degenerative disc disease. Cervical TADR candidacy is limited to skeletally mature individuals with radiculopathy and/or myelopathy at one or two contiguous levels (C3–C7) when device-specific and InterQual clinical criteria are met. Lumbar TDR is considered for skeletally mature adults with symptomatic, intractable single-level discogenic low back pain who meet the policy and InterQual selection criteria.

Background evidence summaries and external guidance underpin the coverage positions: the American Pain Society highlighted limited long-term data for disc replacement, NICE recommended against offering disc replacement for low back pain in 2020, and multiple contemporary evidence reviews (ECRI, Hayes) identify insufficient or minimal support for multilevel and hybrid lumbar constructs — reinforcing the policy's conservative stance where long-term safety and effectiveness remain uncertain.

inv-09 (evidence elements duplicated for context)

Key evidence elements (prospective cohorts, RCTs, and systematic reviews) relevant to lumbar and cervical TDR and hybrid constructs:

Prospective cohorts and RCTs: Randomized trials and prospective cohorts report that single-level lumbar TDR can improve ODI and VAS scores versus baseline and may be comparable to fusion in properly selected patients; follow-up periods in key trials extend to 5-7 years for some devices (e.g., activL, ProDisc-L).

Studies commonly enrolled individuals who failed >= 6 months of conservative care

Policy Revision History

2026-03-01policy_revision

Revised coverage criteria: specified use of FDA‑approved prosthetic discs; limited cervical TADR to one or two contiguous levels (C3‑C7) for skeletally mature individuals with radiculopathy/myelopathy; allowed cervical TADR after prior fusion when radiographically confirmed complete arthrodesis is present; clarified device-level approvals for two‑level cervical procedures; referenced InterQual for clinical criteria; stated cervical artificial disc removal/replacement is medically necessary for implant failure.

2026-03-01policy_revision

Revised lumbar coverage language to require an FDA‑approved prosthetic disc for single‑level lumbar TADR in skeletally mature individuals with symptomatic intractable discogenic low back pain and referenced InterQual Client Defined CP: Procedures, Artificial Disc Replacement, Lumbar (Custom) - UHG; specified lumbar TADR is unproven and not medically necessary when performed with fusion (existing or as part of same plan) or at more than one level.

OpenPayer

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

Coverage Criteria for Cervical and Lumbar Total Artificial Disc Replacement

Procedure and Reference Codes

Provider Actions, Prior Authorization, and Documentation Requirements

Definitions and Key Terms

Background and Evidence Context

Policy Revision History