Prior authorization: confirm FDA approval, single‑level, and imaging evidence

Prior authorization must verify that the planned implant is an FDA‑approved lumbar disc prosthesis used for an FDA‑approved indication and that the procedure is limited to a single lumbar level (L3‑4, L4‑5, or L5‑S1). Prior authorization should also confirm plain radiographs and advanced imaging (CT or MRI) document moderate to severe single‑level disc degeneration at the operative level and absence of degenerative disease at more than one level or above L3‑4.

• Device: FDA‑approved prosthesis and used per labeling
• Level: single‑level only — L3‑4, L4‑5, or L5‑S1
• Imaging: plain X‑rays and CT/MRI confirming moderate to severe single‑level degeneration and absence of multi‑level disease

Prior authorization: verify listed contraindications are absent

Prior authorization must confirm that none of the policy’s listed contraindications or NMN indications are present (e.g., revision of a failed lumbar artificial disc and lumbar partial disc prosthetics).

• Ensure the request is not for revision of a failed lumbar artificial total disc arthroplasty (NMN)
• Ensure the request is not for a lumbar partial disc prosthetic (NMN)

Prior authorization: required documentation (codes, levels, nonsurgical care, independent imaging reads)

Include specific procedure and diagnosis coding with disc levels, and provide detailed nonsurgical treatment records and independent advanced imaging reads when submitting prior authorization.

• CPT codes, ICD‑10 codes, and disc levels/motion segments for planned surgery must be provided
• Detailed documentation of type, duration, frequency, and response to provider‑directed nonsurgical treatments
• Written reports/interpretations of the most recent CT, MRI, or myelography read by an independent radiologist

Prior authorization and code designations (some CPTs NMN)

Prior authorization is required for lumbar total disc arthroplasty and related CPT codes; the policy identifies certain CPT codes as Not Medically Necessary.

• Prior authorization required for procedures described in CPT code section
• Some codes (e.g., 22862, 0165T) are designated Not Medically Necessary (NMN) in the policy

Prior authorization depends on product‑specific coverage

Apply policy criteria only when the member’s product covers lumbar artificial disc replacement; prior authorization requirements are product‑dependent and medical policy criteria do not apply if the product excludes the service.

• If the product does not cover the service, medical policy criteria and prior authorization do not apply
• If the product covers the service (commercial, Medicaid, Medicare without NCD), medical policy criteria apply

Document ≥6 months of medication management and provider‑directed exercise prior to surgery

Document completion and inadequate response to both prescription‑strength medication management (e.g., analgesics, steroids, gabapentinoids or NSAIDs) and a provider‑directed exercise program for at least six consecutive months unless contraindicated.

• At least six (6) consecutive months of multimodal nonoperative treatment
• Both medication management and a provider‑directed exercise/rehabilitation program must show less than clinically meaningful improvement

Policy is not applicable for isolated radicular compressive indications

Do not request lumbar total disc arthroplasty for isolated radicular compression syndromes (e.g., due to disc herniation) or as an adjunct for primary disc herniation; such uses are listed as not medically necessary.

• Isolated radicular compression syndromes are specifically excluded
• Partial disc prosthetics as adjuncts for primary herniation are NMN

Document trials of provider‑directed nonsurgical management and responses

Document provider‑directed trials of nonsurgical management (e.g., interventional pain management, physical therapy, chiropractic care, or active exercise programs) including responses; if a trial was contraindicated, provide an explanation.

• Record type, duration, frequency, and response for each nonsurgical modality
• If nonsurgical trials were contraindicated, include a documented explanation

Require ≥6 months multimodal conservative management before disc replacement

Members must have failed at least six months of multimodal nonoperative treatment including a rehabilitation/physical therapy program before disc replacement is considered.

• Minimum: ≥6 months of multimodal nonoperative care, including physical therapy/rehabilitation
• Failure defined as less than clinically meaningful improvement

Include plain X‑rays and CT/MRI showing single‑level moderate–severe degeneration and symptom concordance

Provide plain radiographs and CT/MRI demonstrating single‑level moderate to severe disc degeneration at L3‑4, L4‑5, or L5‑S1 with symptom concordance (daily significant pain and functional impairment).

• Plain X‑rays and CT/MRI confirming moderate to severe single‑level degeneration
• Document symptom concordance with imaging (daily significant pain and functional impairment)

Document structured, physician‑supervised multi‑modal nonoperative care and failure

Maintain structured, physician‑supervised, multi‑modal nonoperative management records with regular follow‑up and explicit documentation that both medication and a provider‑directed exercise program produced less than clinically meaningful improvement over the required period.

• Regularly scheduled appointments and documented follow‑up evaluations
• Explicit statement of less than clinically meaningful improvement for medication and exercise trials

Provide imaging measurements (disc height, canal width) and DEXA T‑score

Submit imaging measurements and bone density results to confirm eligibility: remaining disc height and mid‑sagittal canal dimensions must meet policy thresholds and DEXA T‑score must be provided to rule out osteopenia/osteoporosis.

• Preoperative remaining disc height documented (policy cites <3 mm as exclusionary)
• Mid‑sagittal stenosis on MRI documented (policy cites <8 mm as exclusionary)
• DEXA T‑score documented (T‑score < −1.0 is a contraindication)

Minimum documentation: CPT/ICD‑10 with levels, detailed nonsurgical treatment and outcomes

Include CPT and ICD‑10 codes with the specific disc levels/motion segments, a detailed chronology of nonsurgical treatments (type, duration, frequency, response), and outcomes for each treatment when submitting prior authorization.

• CPT and ICD‑10 codes plus disc levels/motion segments
• Detailed nonsurgical treatment documentation and outcomes
• Explanation if nonsurgical trials were contraindicated

Document conservative treatment: type, duration, frequency, and response

Record type, duration, frequency, and response for each conservative treatment modality (e.g., interventional pain procedures, physical therapy, chiropractic care, active exercise).

• Conservative treatment details must include response and evidence of less than clinically meaningful improvement

Attach advanced imaging reports read by an independent radiologist

Provide written reports/interpretations of the most recent CT, MRI, or myelography performed, read and interpreted by an independent radiologist; reconcile any clinically significant discrepancies between surgeon and radiologist before submission.

• Advanced imaging must be accompanied by an independent radiologist’s report
• Reconcile any clinically significant interpretation discrepancies prior to submission

Include flexion‑extension plain X‑rays (fusion requests) when indicated

For spinal fusion requests (related situations), include flexion‑extension plain radiographs when indicated for instability and other plain films documenting failure of instrumentation or fusion.

• Flexion‑extension radiographs when instability is a concern
• Plain X‑rays documenting failure of instrumentation or fusion when applicable

Confirm product coverage and Medicare applicability before applying criteria

If the member’s product is Medicare, commercial, or Medicaid, confirm whether the product covers the service; policy criteria apply when the product covers the service and no Medicare NCD applies.

• Confirm product coverage (commercial, Medicaid, Medicare DSNP) before applying policy criteria
• If product does not cover the service, do not apply medical policy criteria

Do not request lumbar partial disc prosthetics (NMN)

Do not submit requests for lumbar partial disc prosthetics — these procedures are designated Not Medically Necessary and are a denial risk.

• Partial disc prosthetics are listed explicitly as not medically necessary

Presence of listed contraindications (revision, low BMD, spondylolisthesis, small disc height, severe stenosis) triggers denial risk

Requests are likely to be denied if any listed contraindications are present, including revision of prior disc arthroplasty, osteopenia/osteoporosis (T‑score < −1.0), spondylolisthesis >3 mm, preoperative remaining disc height <3 mm, or mid‑sagittal stenosis <8 mm by MRI.

• Revision of failed lumbar artificial disc is NMN
• DEXA T‑score ≤ −1.0 (osteopenia/osteoporosis) is a contraindication
• Degenerative or lytic spondylolisthesis >3 mm is exclusionary
• Preoperative remaining disc height <3 mm or mid‑sagittal stenosis <8 mm are exclusionary imaging findings

Denial risk for isolated radicular compression, inadequate endplate size, or compromised vertebral bodies

Requests may be denied when there is isolated radicular compression (e.g., due to disc herniation), when the vertebral endplate is dimensionally smaller than the implant, or when vertebral bodies are clinically compromised from trauma.

• Isolated radicular compression syndromes are not appropriate for disc arthroplasty
• Provide evidence the vertebral endplate dimensions are adequate for the implant

Denial risk: insufficient documentation of failed conservative care

Failure to document the type, duration, frequency, and response to each conservative treatment (including evidence of less than clinically meaningful improvement) can lead to denial of the request.

• Document each conservative modality and outcome in the chart and prior authorization submission

Denial risk: missing independent radiologist reports or unreconciled imaging discrepancies

Lack of written reports from an independent radiologist for the most recent advanced imaging (CT, MRI, or myelography), or unreconciled significant interpretation discrepancies, may result in denial.

• Attach independent radiologist’s reports for advanced imaging
• Resolve any clinically significant surgeon–radiologist interpretation differences prior to submission

Fusion‑related denial risk: missing flexion‑extension or failure‑of‑fusion X‑rays

For related fusion requests, missing flexion‑extension radiographs when instability is indicated or other plain films documenting failure of instrumentation/fusion may lead to denial of those fusion requests.

• Include flexion‑extension X‑rays when instability is relevant
• Provide plain X‑rays documenting failed instrumentation/fusion if applicable

Contract coverage dependency — verify product covers the service

Services are contract dependent; if the member’s product does not include the service, the policy criteria do not apply and denial for lack of coverage is possible.

• Verify whether the member’s product covers lumbar artificial disc replacement before applying policy criteria