Artificial Intervertebral Cervical Disc Form

Health New England Commercial Clinical Policy

Effective Date

Last Reviewed

Original Document

Reference

Artificial Cervical Intervertebral Disc - Medical Policy
Updated Revision Effective: November 1, 2024 Policy Number:

UM484POL

Approval Date: 8/27/2024

Line(s) of Business:

FF
SF
Medicare
MedSupp-G
MedSupp-I
Medicaid

Description

Artificial disc replacement surgery or cervical disc arthroplasty (CDA) is a developing technique for the treatment of cervical radiculopathy that has been used in situations when an anterior cervical discectomy and fusion (ACDF) would otherwise be appropriate. Mounting evidence suggests that CDA is equal or superior to ACDF in terms of clinical outcomes.

 Line of Business

Commercial:

 HNE has adopted InterQual* criteria for the following procedures

o Cervical Total Disc Arthroplasty: CP:Procedures Artificial Disc Replacement, Cervical o Cervical Intervertebral Disc Prosthesis: CP:Procedures Artificial Disc Replacement, Cervical o Cervical Total Disc Replacement: CP:Procedures Artificial Disc Replacement, Cervical

Medicaid – BeHealthy:

 HNE has adopted InterQual* criteria for the following procedures

Medicare:

 HNE has adopted InterQual* criteria for the following procedures

*To obtain InterQual® SmartSheets™: • Health New England Commercial Plan products: If you are a registered Health New England
provider click here: https://www.hnedirect.com/login/ to access the Provider website. If you do not have access to the portal call (413) 787-4004 to obtain a copy.

Policy

I. Cervical Total Disc Arthroplasty, Cervical Intervertebral Disc Prosthesis, Cervical Total Disc Replacement

A. Health New England has adopted following InterQual criteria.

o CP:Procedures Artificial Disc Replacement, Cervical

B. For members under 18 years of age, the request will be reviewed on a case-by-case basis.

C. Cervical total disc arthroplasty, cervical intervertebral disc prosthesis and cervical total disc replacement for all other indications other than in criteria above are considered NOT MEDICALLY NECESSARY

Coding Guidance

Code
Description
PA 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
Yes 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.) Yes

MassHealth does not pay this code No PA Required.

Note: CPT/HCPCS codes are included for informational purposes and may not be all inclusive. Inclusion or exclusion of a CPT/HCPCS code(s) does not signify or imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member’s specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee of payment. Other policies and coverage determination guidelines may apply.

References

Treatment and prognosis of cervical radiculopathy. UpToDate (Last updated on 02/28/2023). https://www.uptodate.com/contents/treatment-and-prognosis-of-cervical- radiculopathy?search=ACDF&source=searchresult&selectedTitle=1~2&usagetype=default&display_rank=1

Policy Implementation

Approved by the Medical and Pharmacy Policy Committee

Kate McIntosh MD MBA

Chief Medical Officer

Saad Usmani MD MBA

Medical Director

Date Update 6/2014 Original policy effective date 12/2023 No changes except references updated. 1/2024 Added Line of Business section 08/2024 Reviewed with no changes.

Medical Criteria Disclaimer

Property of Health New England. All rights reserved. The treating physician or primary care provider must submit to Health New England the clinical evidence that the patient meets the criteria for the treatment, testing or surgical procedure. Without this documentation and information, Health New England will not be able to properly review the request for prior authorization. The clinical review criteria reflect how Health New England determines whether certain services or supplies are medically necessary. Health New England 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).
Health New England 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 Health New England, as some programs exclude coverage for services or supplies that Health New England 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. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.

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Artificial Intervertebral Cervical Disc Form

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