Prior authorization request form Form

Artificial Intervertebral Discs

Last Review Date: October 10, 2025 
Number: MG.MM.SU.46g

Medical Guideline Disclaimer Property of EmblemHealth. All rights reserved. The treating physician or primary care provider must submit to EmblemHealth the clinical evidence that the patient meets the criteria for the treatment or surgical procedure. Without this documentation and information, EmblemHealth will not be able to properly review the request for prior authorization. The clinical review criteria expressed below reflects how EmblemHealth determines whether certain services or supplies are medically necessary. EmblemHealth established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). EmblemHealth expressly reserves the right to revise these conclusions as clinical information changes and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by EmblemHealth, as some programs exclude coverage for services or supplies that EmblemHealth considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication. EmblemHealth Services Company LLC, (“EmblemHealth”) has adopted the herein policy in providing management, administrative and other services to EmblemHealth Plan, Inc., EmblemHealth Insurance Company, EmblemHealth Services Company, LLC and Health Insurance Plan of Greater New York (HIP) related to health benefit plans offered by these entities. All of the aforementioned entities are affiliated companies under common control of EmblemHealth Inc. Definitions Artificial discs Devices constructed from metal, plastic, titanium or polyurethane, which are surgically implanted between the spinal vertebrae as a replacement for diseased/damaged discs to provide relief for intractable pain. Cervical degenerative disc disease (CDD) Defined as neck or arm (radicular) pain and/or a functional/neurological deficit with at least one of the following conditions confirmed by imaging (CT, MRI, or X-rays):

1. Herniated nucleus pulposus
2. Spondylosis (defined by the presence of osteophytes)
3. Loss of disc height. Degenerative disc disease (DDD) Defined as discogenic back pain with degeneration of the disc confirmed by patient history and radiographic studies. Intractable radiculopathy/or myelopathy Defined as any combination of the following:
4. Disc herniation with radiculopathy
5. Spondylotic radiculopathy
6. Disc herniation with myelopathy
7. Spondylotic myelopathy resulting in impaired function and at least one clinical neurological sign associated with the cervical level to be treated, and necessitating surgery as demonstrated using computed tomography (CT), myelography and CT, and/or magnetic resonance imaging (MRI). Spondylolisthesis Defined as anterior or posterior displacement (slippage) of a vertebra or the vertebral column in relation to the vertebrae below; described by millimeters or grading per the table following table.
   Grade 1 0–25% of vertebral body has slipped forward Grade 2 25–50% Grade 3 50–75% Grade 4 75–100% Grade 5 > 100% = vertebral body completely fallen off (i.e., spondyloptosis)

Guideline Artificial discs are FDA-approved for use in skeletally mature individuals per the table below.
(List not intended as all-inclusive)

Device Indication Cervical BRYAN® Cervical Disc Radiculopathy/myelopathy (C3–C7) (single level) M6-C™ Artificial Cervical Disc Radiculopathy/myelopathy (C3–C7) (single level) Mobi-C® Cervical Disc Prosthesis Radiculopathy/myelopathy (C3–C7) (two level) PCM Cervical Disc System Radiculopathy/myelopathy (C3–C7) (single level) Prestige® Cervical Disc System Radiculopathy/myelopathy (C3–C7) (single level) Prestige LP Cervical Disc Radiculopathy/myelopathy (C3–C7) (single level) ProDisc™-C Total Disc Replacement CDD (C3–C7) (single level) SECURE®-C Artificial Cervical Disc Radiculopathy/myelopathy (C3–C7) (single level) Lumbar activL® Artificial Disc DDD (L4–L5 or L5–S1): No ≥ Grade I spondylolisthesis at the involved level (single level) CHARITÉ™ Artificial Disc
DDD (L4-S1): No > 3mm of spondylolisthesis at the involved level (single level) PRODISC®-L Total Disc Replacement DDD (L3–S1): No > Grade 1 spondylolisthesis at involved level (single level) Members with single-level lumbar disc disease (or 1–2 contiguous cervical-level disease) are eligible for coverage of artificial prosthetic disc replacement with an FDA-approved device when the following criteria are met:

1. Skeletal maturity
2. Disease confirmed by radiological imaging (e.g., CT or MRI scan*)
3. Pain confined to operative level(s)
4. Pain score ≥ 40 on Visual Analog Scale (VAS)
5. Disability score ≥ 30 on Oswestry Low Back Pain Disability Questionnaire or Neck Disability Index
6. Failure of ≥ 6 months consistent conservative medical therapy, as evidenced by physician office progress notes, which demonstrates that ≥ 2 of the following having been tried: a. Physical therapy b. Chiropractic care c. Ice/heat therapy d. Pharmacotherapy (e.g., oral/injectable analgesia such as non-steroidal anti-inflammatories, muscle relaxants, epidural/facet injections)
   Limitations/Exclusions Artificial discs are not considered medically necessary when any of the following are applicable, as there is insufficient evidence to demonstrate therapeutic value/safety:
7. Insertion for purposes for which the device is not FDA approved (off-label use)
8. Insertion despite presence of contraindications identified within the specific product labeling

3. Previous spinal fusion/other spinal surgery at affected level
4. Current or previous fracture at affected level

5. Presence of infection Revision history Oct. 10, 2025 Removed discogram prerequisite prior to disc replacement Oct. 8, 2021 Removed prerequisite for grade/millimeter measurement of spondylolisthesis Added the presence of infection as a surgical contraindication
   Oct. 12, 2018 Clarified that discogram is only indicated for the lumbar region Removed “No nerve root compression or narrowing of lateral access” as prerequisite Dec. 9, 2016 Expanded coverage for 1–2 contiguous cervical levels (e.g., Mobi-C®)

   Applicable Procedure Codes 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) 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

   Applicable ICD-10 Diagnosis Codes M47.16 Other spondylosis with myelopathy, lumbar region M47.26 Other spondylosis with radiculopathy, lumbar region M47.27 Other spondylosis with radiculopathy, lumbosacral region M47.816 Spondylosis without myelopathy or radiculopathy, lumbar region M47.817 Spondylosis without myelopathy or radiculopathy, lumbosacral region M47.896 Other spondylosis, lumbar region M47.897 Other spondylosis, lumbosacral region M48.36 Traumatic spondylopathy, lumbar region M48.37 Traumatic spondylopathy, lumbosacral region M50.00 Cervical disc disorder with myelopathy, unspecified cervical region M50.01 Cervical disc disorder with myelopathy, high cervical region M50.020 Cervical disc disorder with myelopathy, mid-cervical region, unspecified level M50.021 Cervical disc disorder at C4-C5 level with myelopathy
   M50.022 Cervical disc disorder at C5-C6 level with myelopathy

M50.023 Cervical disc disorder at C6-C7 level with myelopathy
M50.10 Cervical disc disorder with radiculopathy, unspecified cervical region M50.11 Cervical disc disorder with radiculopathy, high cervical region M50.120 Mid-cervical disc disorder, unspecified
M50.121 Cervical disc disorder at C4-C5 level with radiculopathy
M50.122 Cervical disc disorder at C5-C6 level with radiculopathy
M50.123 Cervical disc disorder at C6-C7 level with radiculopathy
M50.20 Another cervical disc displacement, unspecified cervical region M50.21 Another cervical disc displacement, high cervical region M50.220 Other cervical disc displacement, mid-cervical region, unspecified level
M50.221 Other cervical disc displacement at C4-C5 level
M50.222 Other cervical disc displacement at C5-C6 level
M50.223 Other cervical disc displacement at C6-C7 level
M50.30 Other cervical disc degeneration, unspecified cervical region M50.31 Other cervical disc degeneration, high cervical region M50.320 Other cervical disc degeneration, mid-cervical region, unspecified level
M50.321 Other cervical disc degeneration at C4-C5 level
M50.322 Other cervical disc degeneration at C5-C6 level
M50.323 Other cervical disc degeneration at C6-C7 level M50.80 Other cervical disc disorders, unspecified cervical region M50.81 Other cervical disc disorders, high cervical region M50.820 Other cervical disc disorders, mid-cervical region, unspecified level
M50.821 Other cervical disc disorders at C4-C5 level
M50.822 Other cervical disc disorders at C5-C6 level
M50.823 Other cervical disc disorders at C6-C7 level
M50.90 Cervical disc disorder, unspecified, unspecified cervical region M50.91 Cervical disc disorder, unspecified, high cervical region M50.920 Unspecified cervical disc disorder, mid-cervical region, unspecified level
M50.921 Unspecified cervical disc disorder at C4-C5 level
M50.922 Unspecified cervical disc disorder at C5-C6 level
M50.923 Unspecified cervical disc disorder at C6-C7 level
M51.06 Intervertebral disc disorders with myelopathy, lumbar region M51.16 Intervertebral disc disorders with radiculopathy, lumbar region M51.17 Intervertebral disc disorders with radiculopathy, lumbosacral region M51.26 Other intervertebral disc displacement, lumbar region M51.27 Other intervertebral disc displacement, lumbosacral region

M51.36 Other intervertebral disc degeneration, lumbar region M51.360 Other intervertebral disc degeneration, lumbar region with discogenic back pain only M51.361 Other intervertebral disc degeneration, lumbar region with lower extremity pain only M51.362 Other intervertebral disc degeneration, lumbar region with discogenic back pain and lower extremity pain M51.369 Other intervertebral disc degeneration, lumbar region without mention of lumbar back pain or lower extremity pain M51.370 Other intervertebral disc degeneration, lumbosacralregion with discogenic back pain onl M51.371 Other intervertebral disc degeneration, lumbosacralregion with lower extremity pain only M51.372 Other intervertebral disc degeneration, lumbosacralregion with discogenic back pain and lower extremity pain M51.379 Other intervertebral disc degeneration, lumbosacralregion without mention of lumbar back pain or lower extremity pain M51.86 Other intervertebral disc disorders, lumbar region M51.87 Other intervertebral disc disorders, lumbosacral region Q76.2 Congenital spondylolisthesis References FDA. Medical Devices activL® Artificial Disc – P120024. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpma/pma.cfm?id=P120024. Accessed November 6, 2025. FDA. Medical Devices BRYAN® Cervical Disc - P060023.
https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpma/pma.cfm?id=P060023. Accessed November 19, 2024. FDA. Medical Devices CHARITÉ™ Artificial Disc - P040006. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpma/pma.cfm?id=P040006. Accessed November 6, 2025. FDA. Medical Devices M6-C™ Artificial Cervical Disc - P170036. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpma/pma.cfm?id=P040006. Accessed November 6, 2025. FDA Medical Devices mobi-C® Cervical Disc Prosthesis – P11002. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpma/pma.cfm?id=P110002. Accessed November 6, 2025. FDA Medical Devices PCM Cervical Disc System - P100012. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpma/pma.cfm?id=P100012. Accessed November 6, 2025. FDA Medical Devices PRODISC C® Disc System - P070001. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpma/pma.cfm?id=P070001S007. Accessed November 6, 2025. FDA. Medical Devices. PRODISC®-L Total Disc Replacement - P050010.
https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpma/pma.cfm?id=P050010. Accessed November 6, 2025. FDA. Medical Devices. SECURE®-C Artificial Cervical Disc – P100003. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpma/pma.cfm?id=P060018. Accessed November 6, 2025 FDA. Medical Devices. Prestige LP Cervical Disc - P090029. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpma/pma.cm?id=P100012. Accessed November 6, 2025 FDA. Medical Devices. Prestige Cervical Disc System - P060018. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpma/pma.cfm?id=P060018. Accessed November 6, 2025 FDA. Medical Devices. Secure-C Artificial Cervical Disc - P100003. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpma/pma.cfm?id=P100003. Accessed November 6, 2025. Comparison of anterior cervical discectomy and fusion versus artificial disc replacement for cervical spondylotic myelopathy: a meta- analysis. Chang CJ, Liu YF, Hsiao YM, Huang YH, Liu KC, Lin RM, Lin CL. J Neurosurg Spine. 2022 Apr 22:1-10. doi: 10.3171/2022.2. SPINE211500. PMID: 35453110 Peng Z, Hong Y, Meng Y, Liu H. Int Orthop. 2022 Jul;46(7):1609-1625. doi: 10.1007/s00264-022-05318-z. Epub 2022 Feb 3.PMID: 35113188 Spine Universe. Spondylolisthesis: Back Condition and Treatment. https://www.spineuniverse.com/conditions/spondylolisthesis/spondylolisthesis-back-condition-treatment. Mar. 2019. Accessed November 6, 2025.Specialty-matched clinical peer review.