Artificial Disc Replacement Form

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Artificial Disc Replacement Medical Guideline

Service: Artificial Disc Replacement (Intervertebral Disc Prosthesis, Hybrid TDR- ACDF)

PUM 250-0040

Medical Guideline Committee Approval Q3-2025 Effective Date 03/01/2026

Coverage for Artificial Disc Replacement may vary across plans. Refer to the member’s benefit plan document for coverage details.

Description: Artificial disc replacement is a surgical procedure in which a diseased or damaged intervertebral disc of the spine is replaced with an artificial, man-made (prosthetic) disc.
Artificial disc replacement is proposed as an alternative to spinal fusion.

Indications of Coverage:

A. Single level or two level cervical (neck) artificial disc replacement in a skeletally mature individual is considered medically necessary in adults when ALL (1 through 7) of the following criteria are met:

1. Cervical degenerative disc disease or herniated disc with intractable radiculopathy and/or myelopathy at each level to be replaced.

   AND

2. Imaging study (computed tomography [CT], magnetic resonance imaging [MRI], or x-ray) demonstrates single-level or two contiguous level (touching/neighboring) disc degeneration with at least one of the following: a. Osteophytes b. Herniated nucleus pulposus c. Loss of disc height (compared to adjacent levels)
   d. Disc desiccation or degeneration

   AND

3. The artificial disc replacement is for one to two contiguous spinal levels from cervical 3 through cervical 7 (C3 through C7).

   AND

4. The individual has trialed at least 6 weeks of physician-directed non-operative treatment which did not improve the radiculopathy or myelopathy symptoms. The non-operative treatment trial must include a 6-week trial of physical therapy or

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chiropractic treatment specific to the cervical area of concern AND a trial of anti- inflammatory medication, analgesics, or muscle relaxants.

 Note: The non-operative treatment requirement does not apply to individuals with severe or rapidly progressing symptoms of spinal cord or nerve root compression requiring emergent hospitalization or emergent surgery.

AND

5. The individual has not had a prior spinal surgery at the same level(s)

   AND

6. The individual must also meet the criteria for an anterior cervical decompression fusion (ACDF) (the reviewer will reference MCG Guideline for Cervical Spinal Fusion) AND

7. The artificial disc must be Food and Drug Administration (FDA)-approved and used in accordance with FDA labeling. It is the responsibility of the surgeon to choose an FDA-approved device.

   B. Single level lumbar artificial disc replacement is considered medically necessary when ALL of the following criteria are met:

8. Individual is at least 18 years old. AND

9. The artificial disc replacement is for degenerative disc disease at one level between L3 and S1 (L3-L4, or L4-L5, or L5-S1).

   AND

10. Degenerative disc disease with unremitting discogenic lumbar back pain and/or functional disability have been present for at least one year.

    AND

11. Computed tomography (CT) or magnetic resonance imaging (MRI) verifies moderate to severe single level degenerative disc disease limited to the one level between L3 and S1 that is targeted for replacement.

    AND

12. Within the past 12 months, the individual has failed 6 months of physician supervised conservative medical management, which includes all of the following:

    a. At least 6 weeks of physical therapy (PT) or chiropractic treatment specific to the lumbar area of concern. b. Home exercises to improve core stabilization. c. Anti-inflammatory, analgesic, or muscle relaxant medications (unless contraindication is documented).

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AND

6. The artificial disc must be Food and Drug Administration (FDA)-approved and used in accordance with FDA labeling. It is the responsibility of the surgeon to choose an FDA-approved device.

   C. Revision of a cervical or lumbar intervertebral disc prosthesis is considered medically necessary when imaging confirms failure of the implanted device (e.g., loosening, dislodgement, fracture, infection).

   Limitations of Coverage:

   Benefit Limitations: Please note that in listing services or examples, when we say “this includes,” it is not our intent to limit the description to that specific list. When we do intend to limit a list of services or examples, we state specifically that the list “is limited to.”

   A. Review health plan and endorsements for exclusions and prior authorization or benefit requirements.

   B. If requested/used for a condition or diagnosis other than is listed in the Indications of Coverage, it will be considered experimental, investigational, and unproven to affect health outcome.

   C. If requested/used for a condition or diagnosis that is listed in the Indications of Coverage; but the criteria are not met, it will be considered not medically necessary.

   D. Artificial intervertebral disc replacement will be considered experimental, investigational, and unproven to affect health outcomes if the prosthetic intervertebral disc (implant) used is not Food and Drug Administration (FDA)-approved (or if FDA-approved implant is not used in accordance with FDA labeling).

   E. If requested/used for thoracic level(s), it will be considered experimental, investigational, or unproven to affect health outcomes.

   F. Combined total disc replacement concurrent with fusion (TDR-ACDF Hybrid), prior to or after fusion surgery will be considered experimental, investigational, and unproven to affect health outcomes.

   G. Cervical artificial intervertebral disc replacement will be considered experimental, investigational, and unproven to affect health outcomes in any of the following circumstances:

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1. Individuals with symptomatic degenerative disc disease or herniated disc beyond the proposed surgical location (e.g., at more than one level for single disc or 2 contiguous levels for 2-level disc replacement).

2. If requested/used for more than two (2) contiguous levels.

3. Previous spinal surgery at level(s) being treated.

4. Previous fusion at adjacent cervical level(s)

5. In the presence of any of the following contraindications: a. Tumor or metastatic disease at site(s) of implant(s) or area that could affect the safe exposure of spine required for the procedure.
   b. Active Infection (systemic or at implantation site) c. Radiographic evidence of cervical instability such as greater than 3.5 mm subluxation or greater than 11 degrees of angulation or kyphotic deformity. d. Severe facet degeneration at the operative level

   H. Lumbar artificial intervertebral disc replacement will be considered experimental, investigational, and unproven to affect health outcomes in any of the following circumstances:

6. The individual is less than 18 years old.

7. It is requested/used for more than one lumbar spinal level.

8. The individual has a history of previous lumbar fusion.

9. Lumbar artificial disc replacement is combined with a fusion at any lumbar spinal level.

10. Presence of lumbosacral fracture

11. Presence of lower extremity radiculopathy (nerve root compression) or moderate to severe lumbar spinal stenosis.

12. Presence of Grade 2 or higher spondylolisthesis at targeted level or any degree of listhesis at non-targeted level.

13. Presence of multi-level lumbar degenerative disc disease.

14. In the presence of any of the following contraindications:

    a. Severe facet degeneration at the operative level b. Presence of tumor or metastatic disease at site of implant or area that could affect the safe exposure of spine required for the procedure.

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c. Presence of infection at the implantation site or active systemic infection

I. Spinal navigation systems for any disc replacement are considered integral to the primary procedure.

Documentation Required:

• Standard Written Order (SWO), prescribed by a qualified healthcare provider concerning the member’s diagnosis.
• Medical record information (including continued need/use if applicable) and medical necessity. Office notes and procedure reports • Evidence (therapy/treatment notes) of at least 6 weeks of participation in physical therapy or chiropractic treatment directed at the spinal area/level(s) of concern. • Documentation of the specific prosthesis/implant to be used. • History of previous spinal procedures • Imaging (MRI, CT, CT myelogram) reports • Correct coding for the item/service that meets all the coding guidelines.

Disclaimer: This guideline is for informational purposes only and does not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may or may not provide coverage for all services listed in this guideline. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs medical guideline in all their coverage determinations. Contact customer services as listed on the member card for specific plan, benefit, and network status information.

Medical guidelines are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in administering health benefits. This medical guideline and MCG guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider. To obtain additional information about MCG, email medical.policies@wpsic.com. Coverage of all services is subject to medical necessity and services deemed experimental, investigational, and/or unproven are therefore not considered medically necessary under the terms of the clinical guidelines and will not be covered.

Artificial Disc Replacement are considered medically necessary only when indicated per the most current medical references and specialty society guidelines, such as MCG, NCCN, etc.

State mandates, laws or benchmark supersede this medical guideline.

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Guideline Review History:

Implemented 10/01/17, 10/1/18, 07/01/19, 06/01/20, 03/01/21, 03/01/22, 03/01/23, 03/01/24, 03/01/26 Medical Guideline Committee Approval 06/16/17, 06/15/18, 03/15/19, 02/27/20, 02/25/21, 02/24/22, 02/23/23, 02/28/24, Q3 2025 Reviewed

06/15/18, 03/15/19, 02/27/20, 02/25/21, 02/24/22, 02/23/23, 02/28/24, Q3 2025 Developed 06/16/17 For Artificial Disc review prior to this guideline see MCG 20th edition (effective 3/16/16) and, prior to 3/16/16, Medical Guideline PUM 250-0008 Artificial Disc Replacement and Other Intervertebral Disc Therapies

Approved by the Medical Director

Codes: The following codes for treatments and procedures applicable to this document are included below for informational purposes.

Code Description 0095T REMOVAL OF TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, EACH ADDITIONAL INTERSPACE, CERVICAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 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) 0164T REMOVAL OF TOTAL DISC ARTHROPLASTY, (ARTIFICIAL DISC), ANTERIOR APPROACH, EACH ADDITIONAL INTERSPACE, LUMBAR (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

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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 22864 REMOVAL OF TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, SINGLE INTERSPACE; CERVICAL 22865 REMOVAL OF TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, SINGLE INTERSPACE; LUMBAR 0RP00JZ REPLACEMENT OF CERVICAL VERTEBRAL DISC WITH SYNTHETIC SUBSTITUTE, OPEN APPROACH 0RP10JZ REPLACEMENT OF CERVICOTHORACIC VERTEBRAL DISC WITH SYNTHETIC SUBSTITUTE, OPEN APPROACH 0RP30JZ REVISION OF SYNTHETIC SUBSTITUTE IN CERVICAL VERTEBRAL DISC, OPEN APPROACH 0RP40JZ REVISION OF SYNTHETIC SUBSTITUTE IN CERVICOTHORACIC VERTEBRAL DISC, OPEN APPROACH 0RP50JZ REMOVAL OF SYNTHETIC SUBSTITUTE FROM OCCIPITAL-CERVICAL JOINT, OPEN APPROACH 0RR30JZ REMOVAL OF SYNTHETIC SUBSTITUTE FROM CERVICAL VERTEBRAL JOINT, OPEN APPROACH 0RR50JZ REMOVAL OF SYNTHETIC SUBSTITUTE FROM CERVICAL VERTEBRAL DISC, OPEN APPROACH 0RW30JZ REMOVAL OF SYNTHETIC SUBSTITUTE FROM CERVICOTHORACIC VERTEBRAL JOINT, OPEN APPROACH 0RW50JZ REMOVAL OF SYNTHETIC SUBSTITUTE FROM CERVICOTHORACIC VERTEBRAL DISC, OPEN APPROACH

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