Artificial Intervertebral Cervical Disc Form

Clinical Review Criteria Related to Artificial Intervertebral Cervical Disc Effective 2/1/2023 (Date of Last Review: 11/8/2022) Page 1 of 3 ©2010 Health New England

Clinical Review Criteria Related to Artificial Intervertebral Cervical Disc

Definitions:

• Cervical Radiculopathy: Pain and neurological symptoms from nerve irritation in the cervical spine.
Symptoms can radiate into arm and hand. The symptoms depend upon which nerve is being compressed or inflamed. • Spondylosis: Degenerative changes in the spine which may be the result of bone spurs and/or degenerating intervertebral discs between the vertebrae. These changes are frequently termed osteoarthritis.

Policy:

I. Criteria for Approval: • Health New England has adopted InterQual criteria. • HNE Nurse Reviewers use InterQual. • InterQual criteria are available upon request by members and providers.

II. Required Documentation:

A. Clinical notes from treating Provider to include treatment plan over six-week period of time, CT scan and/or MRI or X-ray reports.

CPT 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

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.)

 Note: MassHealth (Medicaid): A second level of artificial cervical disc is not covered (22858).

 MassHealth code 22858 is payable for the surgeon BUT not the facility (outpatient hospital or surgical center). (10/5/22)

Clinical Review Criteria Related to Artificial Intervertebral Cervical Disc Effective 2/1/2023 (Date of Last Review: 11/8/2022)

©2010 Health New England

Page 2 of 3 Medical Criteria Disclaimer:

Property of Health New England. All rights reserved. Health New England has adopted InterQual criteria that is an evidence-based clinical decision support solution to help payers, providers and government agencies make clinically appropriate medical utilization decisions. The medical criteria contain the applicable HCPCS codes, diagnoses, and accepted standards of practice and are consistent with Clinical Practice Guidelines. The Medical criteria is applied to each aspect of the prospective, concurrent or retrospective review processes.

Health New England Reviews and approves all InterQual criteria. Input from actively practicing physicians/practitioners with relevant expertise is provided through the Utilization Management Committee and the Clinical Care Assessment Committee prior to being adopted by Health New England.

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 Advantage and Medicaid members. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.

REFERENCES:

NCQA Standard, UM 2, Clinical Criteria for Utilization Management Decisions, Element A

Burkus, J. K., Traynelis, V. C., Haid, R. W., & Mummaneni, P. V. (2014, October). Clinical and radiographic analysis of an artificial cervical disc: 7-year follow-up from the Prestige prospective randomized controlled clinical trial: Clinical article. Retrieved July 21, 2022, from:

https://www.ncbi.nlm.nih.gov/pubmed/25036218 Bae, H. W., Kim, K. D., Nunley, P. D., Jackson, R. J., Hisey, M. S., Davis, R. J., . . . Araghi, A. (2015, June 01). Comparison of Clinical Outcomes of 1- and 2-Level Total Disc Replacement: Four-Year Results From a Prospective, Randomized, Controlled, Multicenter IDE Clinical Trial. Retrieved July 21, 2022, from:

https://www.ncbi.nlm.nih.gov/pubmed/25785955 Davis, R. J., Kim, K. D., Hisey, M. S., Hoffman, G. A., Bae, H. W., Gaede, S. E., . . . Stokes, J. K. (2013, November). Cervical total disc replacement with the Mobi-C cervical artificial disc compared with anterior discectomy and fusion for treatment of 2-level symptomatic degenerative disc disease: A prospective, randomized, controlled multicenter clinical trial: Clinical article. Retrieved July 21, 2022, from:

https://www.ncbi.nlm.nih.gov/pubmed/24010901 Cervical Radiculopathy: Surgical Treatment Options - OrthoInfo - AAOS. (n.d.). Retrieved July 21, 2022, from:

https://orthoinfo.aaos.org/en/treatment/cervical-radiculopathy-surgical-treatment-options/ Goldstein, J. (n.d.). Artificial Disc Vs. Anterior Cervical Discectomy and Fusion. Retrieved July 21, 2022, from:

https://www.spine-health.com/treatment/artificial-disc-replacement/artificial-disc-vs-anterior-cervical- discectomy-and-fusion Reiter, M, (3/2011) Cervical Disc Replacement. Retrieved July 21, 2022, from:

https://www.spine.org/KnowYourBack/Treatments/Surgical-Options/Cervical-Disc-Replacement

Clinical Review Criteria Related to Artificial Intervertebral Cervical Disc Effective 2/1/2023 (Date of Last Review: 11/8/2022)

©2010 Health New England

Page 3 of 3 Jenkins NeuroSpine; Artificial Disc Replacement (2021). Retrieved July 21, 2022, from:
https://jenkinsneurospine.com/treatments/artificial-disc- replacement/?utmsource=google&utmmedium=cpc&utmcampaign=Laser%20Spinal%20Surgery%20 Coscob&adgroup=&keyword=artificial%20disc%20replacement&gclid=EAIaIQobChMIsJXxr7a48gIVgd zICh2rXgdbEAAYASAAEgLZ9PDBwE
Mobi-C Cervical Disc (2021). Retrieved July 21, 2022, from :
https://www.cervicaldisc.com/?gclid=EAIaIQobChMI0M2Twbe48gIVht7ICh3aEQ7YEAAYAiAAEgIgf_ D_BwE
Goldstein MD, Jeffrey, Cervical Artificial Disc Replacement Surgery, Spine-health, 1-18-2019. Retrieved July 21, 2022, from:

https://www.spine-health.com/treatment/artificial-disc-replacement/cervical-artificial-disc-replacement- surgery
Veritas Health, Cervical Disc Replacement Surgery Video, Spine-health. Retrieved July 21, 2022, from:
https://www.spine-health.com/video/anterior-cervical-discectomy-and-fusion-acdf-video

Date Policy Changes 8/2022 No significant changes