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CurrentuniverahealthcarePolicy 7.01.63

Artificial Lumbar Intervertebral Disc (Lumbar Total Disc Arthroplasty)

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Defines medical necessity criteria and exclusions for initial primary lumbar total disc arthroplasty (single-level) and references fusion after failed arthroplasty; affects providers submitting requests for coverage under Univera Healthcare.

Policy Summary

Payeruniverahealthcare

PolicyArtificial Lumbar Intervertebral Disc (Lumbar Total Disc Arthroplasty)

Policy CodePolicy 7.01.63

Change TypeNo material changes

Effective DateOct 15, 2026

Last ReviewOct 17, 2024

Next Review DateJun 1, 2027

Key ActionObtain prior authorization with documentation of FDA-approved device, single-level site, ≥6 months of failed multimodal nonoperative care, and required imaging and advanced radiology reports.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18-60eligible age range

single-levellevel limit

≥6 moconservative care

3 mmmin disc height

8 mmmid-sagittal stenosis

min docdocumentation checklist

Coverage Criteria for Lumbar Total Disc Arthroplasty

inv-01: Initial primary lumbar total disc arthroplasty — Covered when ALL of the following are met:

Covered when ALL of the following are met:

Age: Patient aged 18 to 60 years

Device: Use of an FDA-approved lumbar disc prosthesis for an FDA-approved indication and in accordance with FDA labeling

No hybrid surgery: No planned simultaneous fusion at an adjacent lumbar level

Level: Planned implant limited to a single lumbar level at L3-4, L4-5, or L5-S1

Policy Summary

Payeruniverahealthcare

PolicyArtificial Lumbar Intervertebral Disc (Lumbar Total Disc Arthroplasty)

Policy CodePolicy 7.01.63

Change TypeNo material changes

Effective DateOct 15, 2026

Last ReviewOct 17, 2024

Next Review DateJun 1, 2027

SourceLink

On This Page

Facet status: Absence of facet ankylosis or severe facet degeneration at the operative level

Imaging: Plain X-rays and CT/MRI confirm moderate to severe single-level disc degeneration at the operative level, absence of degenerative disease at more than one level, and absence of disease above L3-4

Symptoms concordant with single-level lumbar degenerative disc disease with daily significant pain and clinically significant functional impairment

Functional impact: Significant functional limitations with diminished quality of life and impaired age-appropriate activities of daily living

Conservative care: Structured, physician-supervised, multi-modal non-operative management with regular scheduled appointments and follow-up, showing less than clinically meaningful improvement with BOTH prescription-strength medications (or alternatives) AND a provider-directed exercise program for at least six consecutive months unless contraindicated6 months

Prescribed program may include physical therapy/rehabilitation, pain management, injections, cognitive behavioral therapy, and active exercise

Behavioral health: Absence of unmanaged significant mental or behavioral health disorders (e.g., major depressive disorder, chronic pain syndrome, secondary gain, opioid use disorder, alcohol use disorder)

inv-02: Not Medically Necessary / Contraindications — NMN when ANY of the following conditions or contraindications are present:

Lumbar total disc arthroplasty is considered not medically necessary when ANY of the following conditions or contraindications are present:

Not medically necessary conditions: Lumbar partial disc prosthetics; use as an adjunct for primary central or far-lateral disc herniation; revision of a failed lumbar artificial total disc arthroplasty; individual with osteopenia or osteoporosis (DEXA T-score < -1.0); degenerative or lytic spondylolisthesis > 3 mm; lumbar spinal stenosis; pars interarticularis defect with spondylolysis or isthmic spondylolisthesis; lumbar scoliosis >11 degrees sagittal plane deformity; spinal fracture; infection; presence of tumor or active infection at the implantation site; lumbar nerve root compression or bony spinal stenosis; preoperative remaining disc height < 3 mm; mid-sagittal stenosis < 8 mm by MRI; history of ankylosing spondylitis, rheumatoid arthritis, lupus, or other autoimmune disorder; allergy or sensitivity to implant materials; isolated radicular compression syndromes (especially due to lumbar disc herniation); involved vertebral endplate dimensionally smaller than implant dimensionssee individual items for numeric thresholds

Policy lists these as exclusionary contraindications.

inv-03: Exclusions / Unsuitable anatomy — Not appropriate when ANY of the following anatomic or clinical conditions are present:

Not appropriate when ANY of the following anatomic or clinical conditions are present:

Exclusionary conditions: Isolated radicular compression syndromes (especially due to lumbar disc herniation); involved vertebral endplate is dimensionally smaller than the approximate dimensions of the implant in anterior/posterior and lateral width; clinically compromised vertebral bodies at the affected level due to current or past trauma

From policy statements.

inv-04: Indications for lumbar artificial disc replacement — Covered when ALL of the following are met (alternate criteria set / cross-reference):

Covered when ALL of the following are met

Indications: Pain arising from 1 or 2 level disc disruption involving L3-4, L4-5, and/or L5-S1; symptoms present for at least 6 months and refractory to multimodal nonoperative treatment including a physical therapy/rehabilitation program (may include pain management, injections, cognitive behavioral therapy, active exercise); primary complaint of axial pain (secondary lower extremity pain acceptable)1-2 levels; >=6 months

FDA-approved devices (activL, Charité, ProDisc-L) have PMA indications for one or two levels as described in regulatory section.

inv-05: Contraindications (coverage exclusions) — Not covered / contraindicated when ANY of the following apply (alternate criteria set):

Not covered / contraindicated when ANY of the following apply

Contraindications: Degenerative disc disease at more than 2 levels; significant facet arthropathy at the index level or evidence that pain is primarily facet-mediated; spinal instability/spondylolisthesis greater than Grade I; chronic radiculopathy; osteopenia with DEXA T-score <= -1.0; poorly managed psychiatric disorder; age < 18 or > 60 years; presence of infection or tumor; other trial-based exclusions such as remaining disc height < 3 mm and mid-sagittal stenosis < 8 mmsee items

Includes numeric thresholds referenced in trials and device labeling.

The policy explicitly states that procedures involving lumbar partial disc prosthetics are not medically necessary and will be denied if submitted as the planned service.

The policy excludes use of lumbar total disc arthroplasty as an adjunct treatment for primary central or far-lateral disc herniation and specifies that total disc arthroplasty is not appropriate for isolated radicular compression syndromes. Procedures intended as adjuncts for primary disc herniation or for isolated radicular indications are listed as not medically necessary.

Revision procedures for a failed lumbar artificial total disc arthroplasty are listed as not medically necessary. The policy specifically notes revision CPT codes (for example, 22862 and 0165T) as designated Not Medically Necessary for lumbar total disc arthroplasty replacements.

The policy identifies several anatomy-related exclusions, including isolated radicular compression syndromes (especially due to lumbar disc herniation), an involved vertebral endplate dimensionally smaller than the implant in anterior/posterior or lateral width, and clinically compromised vertebral bodies at the affected level from current or prior trauma. Requests with these anatomic findings are considered inappropriate and may be denied.

The policy lists explicit contraindications including degenerative disc disease at more than 2 levels and the presence of infection or tumor at the implantation site; when either is present the procedure is not covered/contraindicated.

Coverage of lumbar artificial disc procedures is product dependent. If a member's product does not cover the service, the medical policy criteria do not apply and the service is excluded by contract.

Repeated for emphasis: lumbar partial disc prosthetics are considered not medically necessary under this policy and will not be covered.

The policy enumerates multiple explicit not medically necessary conditions and contraindications including: revision of a failed lumbar disc arthroplasty; osteopenia/osteoporosis (DEXA T-score < -1.0); degenerative or lytic spondylolisthesis >3 mm; preoperative remaining disc height <3 mm; mid-sagittal stenosis <8 mm on MRI; autoimmune inflammatory arthritides (eg, ankylosing spondylitis, rheumatoid arthritis, lupus); allergy or sensitivity to implant materials; and isolated radicular compression syndromes, among others.

Certain CPT codes for revision and related procedures are explicitly designated Not Medically Necessary in the policy. Examples called out include 22862 and 0165T (revision/replacement codes).

Coding and Quantitative Thresholds

Required procedure codesmixed

CPT codes

CPT codes for planned surgery must be provided

Required diagnosis codesICD-10

ICD-10 codes

ICD-10 diagnosis codes for planned surgery must be provided

Covered CPT CodesCPTCovered

22857	Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar.
22860	Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression); second interspace, lumbar (add-on).
22865	Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace, lumbar.
0164T	Removal of total disc lumbar arthroplasty (artificial disc), anterior approach, each additional interspace, lumbar (add-on).
0719T	Posterior vertebral joint replacement, including bilateral facetectomy, laminectomy, and radical discectomy, including imaging guidance, lumbar spine, single segment.

Not Medically Necessary (NMN) CPT CodesCPTNot Covered

22862	Revision including replacement of total disc arthroplasty (artificial disc) anterior approach, single interspace, lumbar. (NMN)
0165T	Revision including replacement of total disc lumbar arthroplasty (artificial disc), anterior approach, each additional interspace, lumbar (add-on). (NMN)

HCPCS CodesHCPCS

No codes listed

HCPCS Codes (section present)HCPCS

Not Applicable

HCPCS Codes section present but no specific HCPCS codes listed in this part of the document

ICD-10 Codes (section present)ICD-10

Multiple Codes

ICD-10 Codes section present but no specific ICD-10 codes listed in this part of the document

Duration of conservative therapy

Required durationAt least 6 consecutive months of structured, physician‑supervised, multimodal non‑operative management with less than clinically meaningful improvement

Therapies requiredIncludes BOTH prescription‑strength analgesics/steroids/gabapentinoids or NSAIDs AND a provider‑directed exercise program

DocumentationRecords must show regular follow‑up and failure (less than clinically meaningful improvement) of each therapy unless contraindicated

Preoperative remaining disc height

Contraindication thresholdPreoperative remaining disc height less than 3 mm is listed as a contraindication to lumbar total disc arthroplasty

Trial exclusionSeveral pivotal trials excluded patients with preoperative remaining disc height < 3 mm

Documentation requirementImaging must demonstrate remaining disc height to confirm it is >= 3 mm to avoid exclusion

Mid-sagittal stenosis by MRI

Contraindication thresholdMid‑sagittal canal diameter (by MRI) less than 8 mm is listed as a contraindication to lumbar total disc arthroplasty

Trial exclusionPivotal trial exclusion included mid‑sagittal stenosis < 8 mm on MRI

Imaging requirementMRI reports must document mid‑sagittal canal measurement to confirm it meets threshold

Bone mineral density (T-score)

DEXA T‑score cutoffBone mineral density T‑score less than -1.0 (osteopenia/osteoporosis) is a contraindication to lumbar total disc arthroplasty

Policy languageOsteopenia shown on DEXA with a T‑score <= -1.0 is listed under contraindications

DocumentationDEXA results should be provided with prior authorization to rule out T‑score <= -1.0

Spondylolisthesis displacement

Displacement thresholdDegenerative or lytic spondylolisthesis displacement greater than 3 mm is a contraindication

Relation to gradeSpondylolisthesis > 3 mm corresponds to progression beyond Grade I in some contexts; policy excludes instability greater than Grade I

Imaging requirementStanding lateral radiographs should document degree of slip to assess exclusion

Minimum pre-operative remaining disc height (trial exclusion)

Minimum acceptable heightRemaining disc height of at least 3 mm (pre‑operative) is required — < 3 mm is an exclusion noted in trials and policy

Trial evidenceKey trials excluded patients with pre‑operative remaining disc height < 3 mm

Confirming evidencePreoperative imaging must report disc height measurements for prior authorization

Mid-sagittal stenosis minimum (trial exclusion)

Minimum mid‑sagittal canal diameterMid‑sagittal stenosis of at least 8 mm by MRI is required to avoid exclusion — < 8 mm was an exclusion in trials and policy

Trial exclusionPivotal trial exclusion criteria included mid‑sagittal stenosis < 8 mm

ReportingMRI report should include mid‑sagittal canal measurement for prior authorization

Age range

Age contraindicationsPatients younger than 18 years or older than 60 years are contraindicated for lumbar disc arthroplasty

Policy age rangeIndications state treatment for adults; contraindications list age <18 or >60 years

Eligibility checkPrior authorization must confirm patient age within 18–60 years

Bone mineral density T-score (DEXA cutoff)

DEXA contraindicationDEXA T‑score <= -1.0 (osteopenia/osteoporosis) is listed as a contraindication to lumbar disc arthroplasty

Policy wordingOsteopenia shown on DEXA with a bone mineral density T‑score less than or equal to -1.0

Prior authorization evidenceProvide DEXA results to demonstrate T‑score > -1.0 when seeking approval

Prior Authorization, Documentation, and Provider Requirements

Prior Authorization

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

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

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

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

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

Step Therapy

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

Denial Risk

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

Documentation Required

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

Step Therapy

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

Note

Documentation Required

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)

Documentation Required

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

Documentation Required

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)

Documentation Required

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

Documentation Required

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

Documentation Required

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

Documentation Required

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

Note

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

Denial Risk

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

Denial Risk

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

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

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

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

Denial Risk

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

Billing Rule

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

Background and Context

Lumbar total disc arthroplasty is described as a surgical option intended to reconstruct a single degenerated lumbar disc and to preserve motion at the index level as an alternative to fusion. Appropriate candidate selection relies on age limits, single-level disease (typically L3-4 through L5-S1), absence of severe facet disease, concordant symptoms, and failure of structured nonoperative care prior to surgery.

Definitions and Clinical Terms

Facet ankylosis or severe facet degeneration

DefinitionFacet ankylosis or severe facet degeneration is a clinical or radiographic condition at the operative level that precludes candidacy for total disc arthroplasty

Policy requirementAbsence of facet ankylosis or severe facet degeneration at the operative level is required for coverage

AssessmentFacet status should be documented on imaging reports prior to authorization

Preoperative remaining disc height (definition & threshold)

DefinitionPreoperative remaining disc height is the imaging‑measured residual height of the intervertebral disc; < 3 mm is listed as an exclusion

Policy thresholdPolicy and trials exclude remaining disc height less than 3 mm

Required documentationProvide measured disc height on preoperative imaging for prior authorization

Mid-sagittal stenosis (definition & MRI threshold)

DefinitionMid‑sagittal stenosis is the anteroposterior canal diameter measured on MRI; < 8 mm is listed as an exclusion

Measurement standardMeasure mid‑sagittal canal diameter on MRI to document stenosis severity

Policy thresholdPolicy and trial exclusion threshold: less than 8 mm on MRI

Unsuitable anatomy

Unsuitable anatomic conditionsIsolated radicular compression syndromes (esp. due to disc herniation); vertebral endplate dimensionally smaller than implant; clinically compromised vertebral bodies from current or past trauma

Implant fit concernIf vertebral endplate dimensions are smaller than approximate implant dimensions in AP or lateral width, disc implantation is contraindicated

Clinical implicationRequests with these anatomic findings may be denied and should be documented on imaging prior to submission

Total Artificial Disc

Device definitionTotal Artificial Disc replaces the entire disc (nucleus, annulus, and end plate) and consists of a polyurethane nucleus between two titanium alloy surfaces

ScopeReplaces entire intervertebral disc as an alternative to fusion

DistinctionDiffers from nucleus‑only devices which leave most of the annulus intact

Artificial Disc Nucleus (nucleus arthroplasty)

Device definitionArtificial Disc Nucleus (nucleus arthroplasty) replaces only the degenerative nucleus; most of the annulus is left intact and device often consists of a hydrogel core that absorbs fluid and expands

TerminologyAlso referred to as partial disc replacement or nucleus arthroplasty

Policy stancePartial disc prosthetics/nucleus arthroplasty are considered not medically necessary in this policy

Meyerding Classification

DefinitionMeyerding Classification grades spondylolisthesis by percent slip on standing lateral radiographs: Grade I 0–25%, Grade II 25–50%, Grade III 50–75%, Grade IV 75–100%, Grade V >100%

Use in policyPolicy references instability/spondylolisthesis greater than Grade I as a contraindication

Assessment methodDetermine grade from standing neutral lateral radiographs measuring percent slip

Lumbar artificial disc replacement / lumbar total disc arthroplasty

Procedure definitionLumbar artificial disc replacement (lumbar total disc arthroplasty) is surgical implantation of a prosthetic device to replace a degenerative lumbar intervertebral disc intended to preserve motion as an alternative to fusion

Indications summaryUsed for symptomatic single‑ or two‑level lumbar DDD (L3‑4, L4‑5, L5‑S1) in appropriately selected patients after failed conservative care

Supporting evidenceRandomized trials and comparative studies cited in references support use in selected patients