Prior authorization: device, levels, and candidacy

Prior authorization is required and must document that the planned implant is an FDA‑approved cervical disc prosthesis used for an FDA‑approved indication, that planned reconstruction levels are within C3–C7, and that the implant(s) are single‑level or contiguous two‑level replacements with candidacy for anterior cervical decompression and interbody fusion.

• Document device is FDA‑approved and will be used per FDA labeling.
• Specify intended reconstructive level(s) (C3–C7).
• Confirm number of levels: single or contiguous two‑level.
• Confirm patient is a candidate for single‑ or two‑level anterior cervical decompression and interbody fusion.

Prior authorization required for single‑ or two‑level ACID

Submit prior authorization for single‑level or contiguous two‑level artificial cervical disc replacement at C3–C7 following discectomy; authorization must reflect candidacy for anterior cervical decompression and interbody fusion.

• Procedure must be for a single level or contiguous two levels.
• Implantation must follow discectomy.
• Patient must be a candidate for anterior cervical decompression and interbody fusion.

Imaging required with prior authorization

Include imaging with the prior authorization: resting plain X‑rays (including flexion/extension when indicated) and MRI or CT demonstrating absence of clinically significant instability and imaging concordant with symptoms (cord compression or spinal stenosis).

• Plain X‑rays must show no subluxation/translation >3.5 mm or sagittal angulation >11° (and no kyphotic deformity/spondylolisthesis).
• Provide MRI/CT reports showing neural structure compression concordant with symptoms (e.g., cord compression or cervical stenosis).
• Include flexion/extension lateral views when assessing instability or adjacent‑level TDA success.

Prior authorization for adjacent‑segment cervical TDA

Prior authorization is required for single‑level adjacent‑segment cervical total disc arthroplasty at C3–C7 and must confirm the prior adjacent‑level TDA was performed ≥6 months earlier and that the device to be used is FDA‑approved and used per labeling.

• Prior adjacent‑level TDA must have been performed at least 6 months prior.
• Planned procedure must use an FDA‑approved cervical disc prosthesis consistent with FDA labeling.
• Planned implant must be for a single‑level adjacent segment replacement at C3–C7 following discectomy.

Medical‑necessity prior authorization: document qualifying criteria

Prior authorization must document that the patient meets all applicable clinical criteria for radiculopathy or myelopathy (including age ≥18 for myelopathy) and that an FDA‑approved cervical disc prosthesis will be used in accordance with labeling.

• Confirm patient meets the policy’s listed symptom and exam criteria for radiculopathy or myelopathy.
• Document patient age ≥18 years where specified.
• Confirm device FDA approval and intended use per labeling.

Prior authorization: prior surgery and instability confirmation

Prior authorization must confirm no prior surgery at the operative level and absence of radiographic instability using the policy’s numeric thresholds; include these findings in the submission.

• State explicitly that there are no previous surgeries at the operative level.
• Provide plain X‑ray measurements showing translation ≤3.5 mm and sagittal plane angulation ≤11 degrees.
• If instability findings are present, note that criteria are not met (may result in denial).

Confirm procedure meets policy and procedure‑specific criteria

Ensure the requested procedure meets all policy guidelines and applicable procedure‑specific criteria; prior authorization will be reviewed against those criteria.

• Verify that clinical, imaging, and nonoperative management criteria in the policy are met before submission.
• Prior authorization is required when applying these policy and procedure‑specific criteria.

Screening and imaging requirement for surgical evaluation

Screen all patients being evaluated for spine surgery for urgent/emergent indications and include required imaging findings and documentation of urgency when applicable in the prior authorization.

• Document presence or absence of urgent/emergent criteria per policy.
• Include imaging findings cited in the applicable procedure sections to support urgency if claimed.

Prior authorization: required submission elements (codes, levels, docs)

Include minimum documentation elements with prior authorization: CPT/ICD‑10 codes, disc levels/motion segments, and supporting clinical and imaging documentation as listed under minimum requirements.

• Provide CPT and ICD‑10 codes and specify disc levels/motion segments involved.
• Attach supporting clinical records and imaging reports per the policy’s minimum documentation list.

Prior authorization: indication and nonoperative management

Prior authorization should document diagnosis (radiculopathy or myeloradiculopathy), involved levels (one or two levels C3–C7), and failure of at least 6 weeks of nonoperative management when applicable.

• Specify diagnosis and the exact levels to be treated (one‑ or two‑level C3–C7).
• Document at least 6 weeks of nonoperative management unless progressive or functionally limiting weakness is present.

Prior authorization required for listed CPT and ICD‑10 codes

Obtain prior authorization for procedures billed with the listed CPT codes and supported by the referenced ICD‑10 diagnosis ranges; ensure documentation demonstrates qualifying clinical criteria.

• Include applicable CPT codes (e.g., 22856, 22858, 22861, 22864, 0095T, 0098T).
• Include supporting ICD‑10 diagnosis codes (e.g., M50.00‑M50.023, M50.10‑M50.123, M54.12).

Prior authorization is product‑dependent

Prior authorization requirements depend on product coverage; if the member’s product does not cover the service, medical policy criteria may not apply and the request could be denied by the product.

• Verify product coverage before submitting a prior authorization request.
• If product excludes the service, the medical policy criteria will not authorize coverage.

Conservative therapy: document ≥2 failed treatments (6‑week trials)

Document less than clinically meaningful improvement after at least two conservative treatments: a six‑week trial of prescription‑strength analgesics/steroids/gabapentinoids/NSAIDs and a six‑week provider‑directed exercise program, unless contraindicated.

• Provide records showing 6‑week medication trial and response.
• Provide documentation of a 6‑week provider‑directed exercise program and response.
• If injections were used, document level and response (see additional conservative options).

Conservative therapy requirement: detail treatments and responses

Document inadequate improvement after at least two conservative treatments (medication for 6 weeks, supervised exercise for 6 weeks, and/or epidural/nerve‑root injection at the same level) unless contraindicated.

• Include type, duration, frequency, and response for each nonsurgical treatment.
• If a trial was contraindicated, provide explanation and supporting documentation.

Conservative therapy requirement: at least two treatments documented

Providers must document at least two conservative treatments (prescription analgesics/steroids/gabapentinoids/NSAIDs for 6 weeks and/or a 6‑week supervised exercise program) with less than clinically meaningful improvement, unless contraindicated.

• List each conservative therapy tried and state the outcome (less than clinically meaningful improvement defined as <50% global improvement).
• Include dates and providers who supervised the treatments.

Radiculopathy: conservative therapy requirements for authorization

For radiculopathy, prior authorization must document failure of at least two conservative treatments such as 6 weeks of prescription‑strength analgesics/steroids/gabapentinoids/NSAIDs, a 6‑week provider‑directed exercise program, or an epidural steroid/selective nerve root block at the same level(s).

• Specify which two (or more) therapies were tried and their durations.
• Document that improvement was less than clinically meaningful for each therapy.

Waiver of routine prerequisites for urgent/emergent cases

For confirmed urgent/emergent conditions, routine prerequisites (e.g., requirement for prior nonoperative management, proof of smoking cessation, absence of unmanaged significant behavioral health disorders, or time frame for repeat procedure) may be waived; document the urgent/emergent indication.

• State the urgent/emergent condition and supporting documentation.
• Explain which usual prerequisites are being waived and why, referencing the policy’s urgent/emergent criteria.

Conservative care documentation: detail trials or contraindications

Provide detailed documentation of adequate trials of provider‑directed nonsurgical treatments (type, duration, frequency, response) or document why such trials were contraindicated when submitting prior authorization.

• Include dates, providers, and objective measures of response for each nonsurgical treatment.
• If contraindicated, include clinical rationale and supporting records.

Nonoperative management: document ≥6 weeks before AIDA for radiculopathy

Patients should generally have failed nonoperative care (at least 6 weeks) prior to cervical disc arthroplasty for radiculopathy; prior authorization should document at least 6 weeks of nonoperative management unless progressive or functionally limiting weakness is present.

• Document at least 6 weeks of nonoperative management or rationale for exception (e.g., progressive weakness).
• Include dates and descriptions of nonoperative therapies tried.

Document FDA approval and device labeling, intended levels and number of levels

Document FDA approval status of the device and that it will be used consistent with FDA labeling; include intended reconstructive level(s) (C3–C7) and number of levels (single or contiguous two‑level).

• State device make/model and FDA approval (PMA/approval date) when available.
• Confirm device will be used per FDA labeling.
• Specify intended levels (C3–C7) and number of levels (single or contiguous two‑level).

Required clinical and imaging documentation: MRI/CT concordant with symptoms

Provide MRI/CT reports showing neural structure compression at the requested level(s) that correlate with symptoms and exam, and clearly document the causative pathology (e.g., herniated disc, synovial/arachnoid cyst, central/lateral/foraminal stenosis, or osteophytes).

• Attach radiology reports that describe compressive pathology at the planned level(s).
• State how imaging findings are concordant with the patient’s symptoms and physical exam.

Conservative therapy documentation: record trials and insufficient response

Document prior conservative treatments showing less than clinically meaningful improvement after at least two of the listed options (prescription‑strength analgesics/steroids/gabapentinoids/NSAIDs for 6 weeks; provider‑directed exercise for 6 weeks; epidural/selective nerve root injection), unless contraindicated.

• Include dates, duration, supervising provider, and patient response for each conservative therapy.
• If injections were used, state the level(s) treated and outcome.

Stability imaging documentation: plain X‑rays for instability assessment

Include plain X‑ray reports that document absence of clinically significant cervical instability (no subluxation/translation >3.5 mm, sagittal plane angulation ≤11 degrees, and no kyphotic deformity/reversal of lordosis or spondylolisthesis).

• Provide static lateral and, when indicated, dynamic flexion/extension plain X‑rays with measurements.
• State measured translation and sagittal angulation values.

Behavioral health documentation requirement

Include behavioral health assessment documenting absence of unmanaged significant behavioral health disorders (e.g., major depressive disorder, chronic pain syndrome, secondary gain, or opioid/alcohol use disorder) when submitting documentation.

• Provide behavioral health evaluation or statement indicating no unmanaged significant behavioral health disorder.
• If disorder is present, document management plan and stability.

Document device FDA approval and use per labeling

Document that the device to be implanted is FDA‑approved for the intended indication and that implantation will follow FDA labeling.

• Identify device and provide FDA approval documentation or reference.
• Confirm intended use matches FDA‑approved indication and labeling.

Imaging concordance documentation: MRI/CT linking findings to symptoms

Attach MRI or CT reports that explicitly state findings concordant with the patient's symptoms and physical exam demonstrating cervical spinal cord compression or cervical spinal stenosis.

• Ensure radiology interpretation links imaging abnormalities to clinical signs/symptoms.
• Include images/reports demonstrating cord compression or stenosis at the requested level(s).

Symptom documentation: record listed neurologic symptoms

Document at least one qualifying symptom (e.g., extremity weakness, numbness or pain; fine motor dysfunction or clumsiness; new‑onset bowel/bladder dysfunction; frequent falls) in the clinical record.

• Record specific symptom(s) present and their onset/severity.
• Explain functional impact (e.g., inability to perform ADLs).

Physical exam documentation: record myelopathic/radicular signs

Document physical exam findings supporting the indication (e.g., grip‑and‑release abnormality, ataxic gait, hyperreflexia, Hoffman or Babinski sign, tandem gait ataxia, inverted brachioradialis reflex, increased tone/spasticity, clonus, or myelopathic hand).

• Record which specific exam signs are present and on which side.
• Include serial exam findings when available.

Use FDA‑approved implant and document labeling compliance

Use only cervical disc prostheses approved by the FDA for the intended indication and in accordance with FDA labeling; document the device’s approval status in the submission.

• State device is FDA‑approved and cite approval if available (PMA or approval statement).
• Confirm device will be used per FDA labeling.

Conservative therapy documentation: inadequate improvement after ≥2 therapies

Document inadequate improvement after at least two conservative therapies (prescription‑strength analgesics, steroids, gabapentinoids and/or NSAIDs) for six weeks, unless contraindicated, when submitting prior authorization.

• List the two (or more) conservative therapies tried and provide objective or subjective measures of insufficient improvement.
• Include dates and supervising clinicians.

Imaging documentation: adjacent‑level TDA success and compression at requested level(s)

Provide imaging demonstrating successful adjacent‑level cervical TDA when applicable and MRI/CT evidence of neural structure compression at the requested level(s) concordant with symptoms.

• Include imaging showing adjacent‑level TDA function (flexion/extension views) when evaluating adjacent segment disease.
• Attach MRI/CT reports showing compressive pathology at the requested level(s).

Required clinical documentation: prior surgery status and myelopathy findings

Document no prior surgeries at the operative level and record myelopathic symptoms and detailed physical exam findings per policy when seeking authorization for myelopathy indications.

• State explicitly that there are no previous surgeries at the operative level.
• Document myelopathic symptoms (weakness, numbness, gait disturbance, bowel/bladder dysfunction) and exam signs (grip‑and‑release, hyperreflexia, Hoffmann, Babinski, etc.).

Required imaging correlation: absence of instability and concordant MRI/CT

Provide plain X‑rays and MRI/CT demonstrating absence of clinically significant cervical instability on resting plain X‑rays and imaging findings consistent with symptoms or exam (e.g., cord compression or stenosis).

• Include resting plain X‑rays showing translation ≤3.5 mm and angulation ≤11° and no kyphotic deformity or spondylolisthesis.
• Attach MRI/CT showing compression or stenosis consistent with clinical findings.

Required imaging documentation: include procedure‑specific imaging

Include the imaging findings required by the applicable procedure sections when evaluating individuals for spine surgery; do not omit procedure‑specific imaging requirements.

• Review and include any procedure‑specific imaging elements noted in the policy.
• Attach the cited imaging studies and reports to the authorization.

Procedure coding and levels: include CPT/ICD‑10 and disc levels

Provide CPT codes, ICD‑10 diagnosis codes, and specify disc levels or motion segments involved for the planned surgery in the prior authorization submission.

• List the CPT and ICD‑10 codes being billed.
• Specify the exact disc level(s) or motion segments to be treated.

Nonsurgical treatment history: detail trials and responses

Provide a detailed nonsurgical treatment history: type, duration, frequency, response, and documentation of less than clinically meaningful improvement for each treatment; if contraindicated, document why.

• For each nonsurgical treatment, list start/end dates, provider, frequency, and clinical response.
• If no trial was possible, include documented contraindication rationale.

Advanced imaging reports: include independent radiologist interpretation

Attach written reports/interpretations of the most recent advanced diagnostic imaging (CT, MRI, or Myelography) read by an independent radiologist; reconcile any clinically significant discrepancies between surgeon and radiologist prior to submission.

• Provide final radiology reports and images for recent CT/MRI/Myelography.
• Document reconciliation of any discrepant interpretations between surgeon and radiologist.

Plain X‑rays requirement for fusion requests

For spinal fusion requests include flexion‑extension plain X‑rays when indicated for instability and/or plain X‑rays documenting failure of instrumentation or fusion.

• Provide flexion‑extension views when assessing for instability in fusion requests.
• Include X‑rays documenting failed instrumentation or nonunion when relevant.

Clinical trial and device‑specific outcome documentation

When citing clinical trial follow‑up data or device‑specific outcomes in support of a request, include device type, level(s) treated, and prior nonoperative treatment duration.

• State device type and levels treated in clinical trial data provided.
• Include prior nonoperative treatment duration when using trial outcomes as supporting evidence.

Device regulatory documentation: cite FDA approval status and indications

Reference device FDA approval status and indication (e.g., device‑specific PMA or approval statement) in the documentation when applicable.

• Cite PMA or FDA approval statement for the device when available.
• Include approval date and indicated levels/uses per FDA labeling.

Applicability: confirm product coverage before submitting

Verify product coverage before applying the medical policy; if the member’s product does not cover the service, the medical policy criteria do not authorize benefit and the request may be denied by the product.

• Confirm whether the commercial, Medicaid, or Medicare product covers the specific service.
• If product excludes the service, do not rely solely on the medical policy for authorization.

Denial risk: prior surgery at the operative level

Prior surgery at the operative level disqualifies initial/primary implant eligibility and should be documented; presence of prior surgery may lead to denial.

• State explicitly if there has been any previous surgery at the operative level.
• If prior surgery exists, note that initial/primary implant criteria are not met.

Denial risk: radiographic cervical instability

Document and report radiographic cervical instability; the presence of subluxation/translation >3.5 mm, sagittal plane angulation >11 degrees, kyphotic deformity/reversal of lordosis, or spondylolisthesis will contraindicate coverage and may result in denial.

• Provide measured translation and sagittal angulation values on plain X‑rays.
• If any instability finding is present, note that coverage criteria are not met.

Denial risk: prior surgery excludes adjacent‑segment indication

Prior surgery at the operative level is disqualifying for the single‑level adjacent segment replacement indication; document absence of prior surgery to avoid denial.

• Confirm no prior surgery at the operative level when requesting adjacent‑segment TDA.
• If prior surgery exists, the adjacent‑segment replacement indication is not met.

Denial risk: instability findings contraindicate coverage

Presence of clinically significant cervical instability (subluxation/translation >3.5 mm, sagittal angulation >11°, kyphotic deformity or spondylolisthesis) may contraindicate coverage and lead to denial.

• Ensure flexion/extension and resting plain X‑rays are included to assess for instability.
• If instability is present, document and counsel that coverage criteria are unmet.

Denial risk: radiographic instability exclusions on plain X‑rays

Resting plain X‑rays showing clinically significant cervical instability (translation >3.5 mm, sagittal plane angulation >11 degrees, kyphotic deformity or spondylolisthesis) will trigger denial; include X‑ray measurements in the record.

• Provide static lateral and flexion/extension X‑ray measurements.
• Note that any listed instability findings render the request not consistent with coverage.

Denial risk: non‑indicated procedures and repeat TDA

Procedures performed for degenerative disc disease as the sole indication, repeat cervical TDA at the same level, or procedures not meeting policy guidelines/procedure‑specific criteria are considered not medically necessary and may be denied.

• Do not submit for degenerative disc disease as sole indication without other qualifying criteria.
• Repeat cervical TDA at the same level is considered not medically necessary.

Denial risk: imaging‑based contraindications (severe facet arthropathy, OPLL)

Imaging evidence of severe facet joint arthropathy or OPLL are contraindications that render the artificial cervical intervertebral disc investigational and may trigger denial; report these imaging findings if present.

• If severe facet arthropathy or OPLL is present on imaging, indicate that the device is investigational for this indication.
• Such findings may result in denial of coverage.

Denial risk: incomplete advanced imaging documentation

Failure to provide written reports/interpretations of the most recent advanced diagnostic imaging (CT, MRI, or Myelography) read by an independent radiologist, or failure to reconcile significant discrepancies between surgeon and radiologist, may risk denial.

• Include independent radiologist’s report for recent CT/MRI/Myelography.
• Document reconciliation of any clinically significant interpretation discrepancies.

Denial risk: incomplete procedure and nonsurgical treatment documentation

Insufficient documentation of CPT/ICD‑10 codes, disc levels, or inadequate detail on type, duration, frequency, and response to nonsurgical treatments (including lack of documentation of less than clinically meaningful improvement) may trigger denial.

• Provide full CPT/ICD‑10 coding and exact disc levels.
• Include detailed nonsurgical treatment history with outcomes for each therapy.

Denial risk: use of non‑FDA‑approved devices (investigational)

Devices that are not FDA‑approved (for example, partial disc replacement systems) are considered investigational and may be denied; do not propose non‑FDA‑approved devices for covered indications.

• Use only devices with documented FDA approval for the intended indication.
• Partial disc replacement systems and other non‑FDA‑approved devices are investigational.

Denial risk: unsupported indications (≥3 levels or isolated axial neck pain)

Procedures for three or more levels or for isolated axial neck pain are not supported by significant evidence and may be denied; ensure requests are limited to one or two levels and have radiculopathy/myeloradiculopathy indications.

• Do not request coverage for three or more levels.
• Do not request coverage for isolated axial neck pain without radiculopathy/myeloradiculopathy.

Denial risk: product coverage dependency

Services are contract dependent; if the member’s product does not cover the service, medical policy criteria do not authorize benefit and the request may be denied by the product—verify contract coverage before submission.

• Confirm beneficiary’s product covers the service before relying on the medical policy.
• If product excludes the service, authorization under this policy will not ensure coverage.

Plain X‑rays required for fusion requests

Plain X‑rays are required for evaluation of fusion requests to document instability (flexion‑extension views when indicated) and/or failure of instrumentation or fusion; include these films and reports when applicable.

• Include flexion‑extension views for instability assessment in fusion requests.
• Attach plain X‑rays documenting failed instrumentation or nonunion when relevant.

Clinical trial follow‑up and device‑specific outcome documentation

When clinical trial follow‑up data or device‑specific outcomes are cited, documentation should include the device type, treated level(s), and prior nonoperative treatment duration to support the request.

• Provide device type and levels treated when citing trial data.
• Include prior nonoperative treatment duration in the supporting documentation.