Humana Commercial Clinical Policy

Humana Artificial Intervertebral Disc Replacement Form

Effective Date

03/23/2023

Last Reviewed

NA

Original Document

  Reference



Description

Artificial intervertebral disc replacement is an alternative to cervical and lumbar spinal fusion surgery for an individual suffering from back or neck pain due to degenerative disc disease (DDD). The artificial disc was designed to restore normal disc height, to preserve spinal flexibility and decrease degeneration of adjacent discs, which can occur as a result of DDD.

Examples of US Food & Drug Administration (FDA) devices approved for single-level cervical spine intervertebral disc replacement include, but may not be limited to:

  • M6-C cervical disc
  • MOBI-C cervical disc
  • PCM cervical disc
Artificial Intervertebral Disc Replacement

Effective Date: 03/23/2023
Revision Date: 03/23/2023
Review Date: 03/23/2023
Policy Number: HUM-0442-023

Humana's documents are updated regularly online.

When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Prestige LP cervical disc system • ProDisc C, ProDisc C Novo, ProDisc C SK, ProDisc C Vivo total disc replacement • SECURE-C artificial cervical disc • Simplify cervical artificial disc

Examples of FDA-approved devices for single- or two-level cervical spine intervertebral disc replacement include, but may not be limited to:

  • MOBI-C cervical disc
  • Prestige LP cervical disc system
  • Simplify cervical artificial disc

Examples of FDA-approved devices for the lumbar spine include, but may not be limited to:

  • activL artificial disc
  • ProDisc L total disc replacement

Coverage Determination

Services provided by a psychiatrist, psychologist or other behavioral health professionals are subject to the provisions of the applicable behavioral health benefit.

Please refer to the member’s applicable pharmacy benefit to determine benefit availability and the terms and conditions of coverage for medication for the treatment of smoking cessation.

Cervical Commercial Plan members:

requests for revision and/or replacement of a cervical artificial intervertebral disc require review by a medical director.

Humana members may be eligible under the Plan for the use of an FDA-approved cervical artificial intervertebral disc(s) replacement at one level or two contiguous levels from C3 to C7 when ALL of the following criteria are met:

Artificial Intervertebral Disc Replacement

Effective Date: 03/23/2023
Revision Date: 03/23/2023
Review Date: 03/23/2023
Policy Number: HUM-0442-023

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • Radiographic confirmation (eg, computed tomography [CT] scan, magnetic resonance imaging [MRI]) of any of the following:
    1. Herniated nucleus pulposus; OR
    2. Spondylosis (defined as presence of osteophytes); OR
    3. Visible loss of disc height as compared to adjacent levels; AND
  • Absence of contraindications; AND
  • Documentation of skeletal maturity*; AND
  • Failure of at least 6 consecutive weeks of conservative treatment under the direction of a healthcare professional within the past 12 months with ALL of the following:
    1. Modification of pain-inducing activities; AND
    2. Nonsteroidal anti-inflammatory drugs (NSAIDs) if medically appropriate and not contraindicated; AND
    3. Oral glucocorticoids if medically appropriate and not contraindicated; AND
    4. Physical therapy (PT) including a home exercise program (HEP)(for information regarding coverage determination/limitations, please refer to Physical Therapy and Occupational Therapy Medical Coverage Policy); AND
  • Implantation via an anterior approach;AND ONE of the following:
    1. Intractable neck pain; OR
    2. Progressive radicular arm pain; OR
    3. Progressive functional neurological deficit (eg, motor weakness, sensory deficit)
Artificial Intervertebral Disc Replacement

Effective Date: 03/23/2023
Revision Date: 03/23/2023
Review Date: 03/23/2023
Policy Number: HUM-0442-023 Page: 4 of 18

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Revision or Replacement of a Cervical Artificial Intervertebral Disc

Humana members may be eligible under the Plan for revision or replacement of a cervical artificial intervertebral disc at the same level(s) as the previous surgery when ALL of the following criteria are met:

  • Original surgery was performed with an FDA-approved device, and in accordance with those approved indications; AND
  • Imaging studies confirm implanted device mechanical failure (eg, dislodgement, implanted device breakage, infection loosening, vertebral body fracture); AND
  • Symptoms were relieved by original procedure, but reoccurred upon failure of the implanted device

Lumbar Commercial Plan members:

requests for revision and/or replacement of a lumbar artificial intervertebral disc require review by a medical director.

Humana members may be eligible under the Plan for the use of FDA-approved lumbar artificial intervertebral disc for replacement at one level from L3 to S1 (activL, ProDisc L) when ALL of the following criteria are met:

  • Degenerative disc disease confirmed by a complex imaging study (eg, CT, MRI, positive concordant discography); AND
  • Absence of contraindications; AND
  • Documentation of skeletal maturity*; AND
  • Failure of at least 6 consecutive months of conservative treatment under the direction of a healthcare professional within the past 12 months with ALL of the following:
    1. Epidural steroid injections if medically appropriate and not contraindicated (for information regarding coverage determination/limitations, please refer to Injections for Chronic Pain Conditions Medical Coverage Policy; AND
Artificial Intervertebral Disc Replacement

Effective Date: 03/23/2023
Revision Date: 03/23/2023
Review Date: 03/23/2023
Policy Number: HUM-0442-023 Page: 5 of 18

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • Modification of pain-inducing activities; AND
  • NSAIDs if medically appropriate and not contraindicated; AND
  • PT including a home exercise program (HEP) (for information regarding coverage determination/limitations, please refer to Physical Therapy and Occupational Therapy Medical Coverage Policy); AND
  • Implantation via an anterior retroperitoneal approach; AND
  • No more than grade I spondylolisthesis at the involved level; AND
  • Presurgical psychological evaluation conducted by a qualified behavioral health provider to identify surgical readiness and potential postoperative challenges that may contribute to a poor postoperative outcome; AND
  • Unremitting low back pain and functional impairment

Skeletally mature refers to a system of fused skeletal bones which occurs when bone growth ceases. Functional impairment is defined as a direct and measurable reduction in physical performance of an organ or body part limiting the ability to perform activities of daily living such as bathing, dressing and mobility (eg, sit, stand, walk) due to illness or pain.

Revision or Replacement of a Lumbar Artificial Intervertebral Disc

Humana members may be eligible under the Plan for revision or replacement of a lumbar artificial intervertebral disc at the same level as the previous surgery when ALL of the following criteria are met:

  • Original surgery was performed with an FDA-approved device, and in accordance with those approved indications; AND
  • Imaging studies confirm implanted device mechanical failure (eg, dislodgement, implanted device breakage, infection loosening, vertebral body fracture); AND
  • Symptoms were relieved by original procedure, but reoccurred upon failure of the implanted device

Note: The criteria for lumbar artificial intervertebral disc replacement are not consistent with the Medicare National Coverage Policy and therefore may not be applicable to Medicare members. Refer to the CMS website for additional information.

Coverage Limitations

Artificial intelligence-based (AI) augmented reality (AR) guidance and computer spinal navigation systems including, but not limited to, the Caduceus S, HOLO Portal System, Stryker Q Guidance System and Surgalign ARAI System are considered integral to the primary procedure and not separately reimbursable.

Cervical Humana members may NOT be eligible under the Plan for cervical artificial intervertebral disc replacement for any indications other than those listed above including, but may not be limited to:

  • Cervical disc replacement at more than 2 levels; OR
  • Partial cervical disc replacement; OR
  • Planned procedure includes combined use of a cervical artificial intervertebral disc replacement adjacent to a spinal fusion (also referred to as hybrid surgery); OR
  • Prior fusion at an adjacent cervical level; OR
  • Prior surgery at the planned treated level

Artificial Intervertebral Disc Replacement Effective Date: 03/23/2023
Revision Date: 03/23/2023
Review Date: 03/23/2023
Policy Number: HUM-0442-023 Page: 7 of 18

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

This is considered experimental/investigational as it is not identified as widely used and generally accepted for any other proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

Humana members may NOT be eligible under the Plan for cervical artificial intervertebral disc replacement for any of the following contraindications:

  • Active or chronic infection, systemic or infection localized to the operative site; OR
  • Allergy or sensitivity to the implant materials (eg, aluminum, ceramic, chromium, cobalt, ethylene oxide, hydroxyapatite, molybdenum, PEEK, polyethylene, polyurethane, stainless steel, titanium, vanadium); OR
  • Compromised vertebral bodies at the affected level(s) due to the following:
    • Current or previous trauma to the cervical spine (eg, radiographic appearance of fracture callus, malunion or nonunion); OR
    • Significant cervical anatomical deformity or disease (eg, ankylosing spondylitis, malignancy, rheumatoid arthritis); OR
  • Congenital stenosis; OR
  • Marked cervical instability on neutral resting lateral and/or flexion/extension radiographs, with greater than 3 millimeters (mm) translation or greater than 11 degrees of angular difference to that of either adjacent level or either level adjacent to the two treated levels; OR
  • Moderate or severe spondylosis at the level to be treated, characterized by any of the following:
    • Absence of motion less than 2 degrees; OR
    • Bridging osteophytes; OR
    • Loss of greater than 50% normal disc height; OR

Artificial Intervertebral Disc Replacement Effective Date: 03/23/2023
Revision Date: 03/23/2023
Review Date: 03/23/2023
Policy Number: HUM-0442-023 Page: 8 of 18

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • Osteoporosis or osteopenia, defined as dual energy X-ray absorptiometry (DEXA) bone density measured T-score less than or equal to negative 1.0; OR
  • Severe facet (zygapophyseal) disease or degeneration; OR
  • Significant kyphotic deformity or severe symptoms (impaired breathing, significant pain, severe functional impairment) or significant reversal of lordosis (eg, curve is running in the wrong direction, loss of normal curve in neck)

These are considered experimental/investigational as they are not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Lumbar Humana members may NOT be eligible under the Plan for artificial intervertebral disc replacement for the lumbar spine for any indications other than those listed above including, but may not be limited to:

  • Multilevel lumbar disc replacement (eg, ProDisc L total disc); OR
  • Planned procedure includes combined use of a lumbar artificial intervertebral disc replacement adjacent to a spinal fusion (also referred to as hybrid surgery); OR
  • Prior surgery at the planned treated level other than prior microdiscectomy with proposed placement of the activL artificial disc

This is considered experimental/investigational as it is not identified as widely used and generally accepted for any other proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

Humana members may NOT be eligible under the Plan for lumbar artificial intervertebral disc replacement for any of the following contraindications36,43:

  • Abdominal pathology precluding an anterior retroperitoneal approach; OR
  • Artificial Intervertebral Disc Replacement Effective Date: 03/23/2023 Revision Date: 03/23/2023 Review Date: 03/23/2023 Policy Number: HUM-0442-023 Page: 9 of 18
  • Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
  • Active or chronic infection, systemic or infection localized to the operative site; OR
  • Allergy or sensitivity to the implant materials (eg, calcium phosphate, cobalt, chromium, molybdenum, polyethylene, tantalum or titanium); OR
  • Bony lumbar stenosis; OR
  • Chronic radiculopathy over a period of at least 1 year; OR
  • Clinically compromised vertebral bodies at the affected level due to current or past disease (eg, ankylosing spondylitis) or trauma (eg, fracture); OR
  • Extruded disc material with sequestrum (free disc fragment); OR
  • Facet ankylosis or facet joint degeneration; OR
  • Involved vertebral endplate dimensionally smaller than 31 mm for activL or 34.5 mm for ProDisc L in the medial lateral and/or 26 mm for activL or 27 mm for ProDisc L in the anterior posterior directions; OR
  • Isolated lumbar radiculopathy, especially due to herniated disc; OR
  • Myelopathy; OR
  • Osteoporosis or osteopenia defined as DEXA bone mineral density T-score less than or equal to negative 1.0; OR
  • Pars defect; OR
  • Preoperative remaining disc height less than 3 mm; OR
  • Scoliosis; OR
  • Spondylolisthesis (degenerative, isthmic or lytic) greater than grade I or segmental instability

Artificial Intervertebral Disc Replacement Effective Date: 03/23/2023 Revision Date: 03/23/2023 Review Date: 03/23/2023 Policy Number: HUM-0442-023 Page: 10 of 18

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

These are considered experimental/investigational as they are not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Additional information about DDD and intervertebral disc herniation may be found from the following websites:

  • Background
    American Academy of Orthopaedic Surgeons
    National Library of Medicine

Medical Alternatives

Alternatives to artificial intervertebral disc replacement for the cervical or lumbar spine include, but may not be limited to, the following:

  • Cervical or lumbar fusion (please refer to Spinal Fusion Surgery Medical Coverage Policy)
  • Spinal decompression surgery (please refer to Spinal Decompression Surgery Medical Coverage Policy)

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.

Artificial Intervertebral Disc Replacement

Effective Date: 03/23/2023
Revision Date: 03/23/2023
Review Date: 03/23/2023
Policy Number: HUM-0442-023 Page: 11 of 18

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar

  • 22857

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)

  • 22858

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)

  • 22860 Not Covered New Code Effective 01/01/2023

Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical

  • 22861 Medical Director Review Required

Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar

  • 22862 Medical Director Review Required

Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical

  • 22864

Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar

  • 22865

CPT® Category Ill Code(s)

  • 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) Medical Director Review Required

0163T

Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), each additional interspace, lumbar (List separately in addition to code for primary procedure)
Not Covered Deleted Code Effective 12/31/2022

Artificial Intervertebral Disc Replacement Effective Date: 03/23/2023
Revision Date: 03/23/2023
Review Date: 03/23/2023
Policy Number: HUM-0442-023 Page: 12 of 18

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.
Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

0164T Removal of total disc arthroplasty, (artificial disc), anterior approach, each additional interspace, lumbar (List separately in addition to code for primary procedure)

  • Not Covered

016ST Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, lumbar (List separately in addition to code for primary procedure)

  • Not Covered

References

  1. Balderston J, Gertz Z, McIntosh T, Balderston R. Long-term outcomes of 2-level total disc replacement using ProDisc-L. Spine. 2014;39(11):906-910.
  2. Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). Lumbar artificial disc replacement (LADR) (150.10).
  1. Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). Lumbar artificial disc replacement (LADR) (150.10). https://www.cms.gov. Published August 14, 2007. Accessed February 24, 2023.
  2. ClinicalKey. Chang C, Wu J, Robinson L, Mummaneni P. Cervical arthroplasty. In: Winn H. Youmans and Winn Neurological Surgery. 8th ed. Elsevier; 2023:2785-2787.e1. https://www.clinicalkey.com. Accessed February 22, 2023.
  3. ClinicalKey. Derman P, Zigler J, Guyer R, Blumenthal S, Lieberman I. Lumbar disk arthroplasty. In: Winn H. Youmans and Winn Neurological Surgery. 8th ed. Elsevier; 2023:2788-2793.e2. https://www.clinicalkey.com. Accessed February 22, 2023.
  4. ClinicalKey. Devlin VJ. Pathology and pathoanatomy of degenerative disorders of the adult spine. In: Devlin VJ. Spine Secrets. 3rd ed. Elsevier; 2021:430-435.e1. https://www.clinicalkey.com. Accessed February 22, 2023.
  5. ClinicalKey. Koutsogiannis P, Khan S, Phillips F, et al. A cross-sectional analysis of 284 complications of lumbar disc replacements from medical device reports maintained by the United States Food and Drug Administration. Spine J. 2022;22:278-285. https://www.clinicalkey.com. Accessed January 31, 2022.
  6. ClinicalKey. Perfetti D, Galina J, Derman P, Guyer R, Ohnmeiss D, Satin A. Risk factors for reoperation for lumbar total disc replacement at short-, mid-, and long-term follow-up. Spine J. 2021;21:1110-1177. https://www.clinicalkey.com. Accessed July 7, 2021.
  7. ClinicalKey. Platt A, Kasliwal M, Traynelis V. Cervical total disc arthroplasty. In: Steinmetz M, Berven S, Benzel E. Benzel’s Spine Surgery. 5th ed. Elsevier; 2022:990-993.e3. https://www.clinicalkey.com. Accessed February 22, 2023.
  8. ClinicalKey. Satin A, Derman P, Guyer R. Lumbar total disc arthroplasty. In: Steinmetz M, Berven S, Benzel E. Benzel’s Spine Surgery. 5th ed. Elsevier; 2022:1088-1098.e3. https://www.clinicalkey.com. Accessed February 22, 2023.
  9. ClinicalKey. Warner WC, Sawyer JR. Scoliosis and kyphosis. In: Azar FM, Beaty JH. Campbell’s Operative Orthopaedics. 14th ed. Elsevier; 2021:1999-2196.e28. https://www.clinicalkey.com. Accessed February 22, 2023.
  10. ECRI Institute. Clinical Comparison. Overview of five implants for cervical artificial disc replacement surgery. https://www.ecri.org. Published April 1, 2020. Accessed February 21, 2023.
  11. ECRI Institute. Clinical Evidence Assessment. Simplify cervical artificial discs (Simplify Medical, Inc.) for treating cervical degenerative disc disease. https://www.ecri.org. Published March 30, 2021. Accessed February 21, 2023.
  12. ECRI Institute. Emerging Technology Evidence Report. Artificial intervertebral disc replacement (AIDR) for lumbar degenerative disc disease (DDD). https://www.ecri.org. Published March 12, 2004. Updated October 14, 2009. Accessed February 21, 2023.
  13. ECRI Institute. Evidence Report. Artificial intervertebral disc replacement for treating cervical disc disease. https://www.ecri.org. Published September 21, 2012. Accessed February 21, 2023.

Artificial Intervertebral Disc Replacement Effective Date: 03/23/2023 Revision Date: 03/23/2023 Review Date: 03/23/2023 Policy Number: HUM-0442-023 Page: 13 of 18

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  1. ECRI Institute. Product Brief. M6-C artificial cervical disc (Spinal Kinetics LLC) for treating cervical degenerative disc disease. https://www.ecri.org. Published March 15, 2020. Accessed February 21, 2023.
  1. ECRI Institute. Product Brief. Mobi-C artificial cervical disc (Zimmer Biomet) for treating degenerative cervical disc disease. https://www.ecri.org. Published September 19, 2016. Updated April 10, 2020. Accessed February 21, 2023.
  2. ECRI Institute. Product Brief. Prestige LP cervical disc (Medtronic plc.) for treating degenerative disc disease. https://www.ecri.org. Published April 8, 2020. Accessed February 21, 2023.
  3. ECRI Institute. Product Brief. ProDisc C cervical total disc replacement system (Centinel Spine, LLC) for treating degenerative disc disease. https://www.ecri.org. Published January 17, 2012. Updated March 25, 2020. Accessed February 21, 2023.
  4. ECRI Institute. Product Brief. Secure-C cervical artificial disc (Globus Medical, Inc.) for treating degenerative cervical disc disease. https://www.ecri.org. Published March 30, 2020. Accessed February 21, 2023.
  5. ECRI Institute. Product Brief (ARCHIVED). ActivL artificial disc (Aesculap, Inc.) for lumbar disc arthroplasty. https://www.ecri.org. Published August 1, 2018. Accessed February 21, 2023.
  6. Hayes, Inc. Clinical Research Response (ARCHIVED). M6-C artificial cervical disc (Orthofix) for the treatment of cervical degenerative disc disease. https://evidence.hayesinc.com. Published October 1, 2020. Accessed February 21, 2023.
  7. Hayes, Inc. Medical Technology Directory. Comparative effectiveness review of lumbar total disc replacement for degenerative disc disease. https://evidence.hayesinc.com. Published April 1, 2019. Updated May 24, 2022. Accessed February 21, 2023.
  8. Hayes, Inc. Medical Technology Directory (ARCHIVED). Comparative effectiveness review of multilevel artificial disc replacement for cervical degenerative disc disease. https://evidence.hayesinc.com. Published October 3, 2017. Updated November 18, 2021. Accessed February 21, 2023.
  9. Hayes, Inc. Medical Technology Directory (ARCHIVED). Comparative effectiveness review of single-level artificial disc replacement for cervical degenerative disc disease. https://evidence.hayesinc.com. Published August 21, 2017. Updated September 22, 2021. Accessed February 21, 2023.

Artificial Intervertebral Disc Replacement Effective Date: 03/23/2023 Revision Date: 03/23/2023 Review Date: 03/23/2023 Policy Number: HUM-0442-023 Page: 15 of 18

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

International Society for the Advancement of Spine Surgery (ISASS). 2021 position statement from the International Society for the Advancement of Spine Surgery on cervical and lumbar disc replacement. https://www.isass.org. Published February 2021. Accessed February 27, 2023.

  1. MCG Health. Disk arthroplasty, cervical. 26th edition. https://www.mcg.com. Accessed February 10, 2023.
  2. MCG Health. Disk arthroplasty, lumbar. 26th edition. https://www.mcg.com. Accessed February 10, 2023.
  3. North American Spine Society (NASS). Coverage Policy Recommendations. Cervical artificial disc replacement. https://www.spine.org. Published November 2015. Accessed February 27, 2023.
  4. North American Spine Society (NASS). Coverage Policy Recommendations. Lumbar artificial disc replacement. https://www.spine.org. Published February 2019. Accessed February 27, 2023.
  5. North American Spine Society (NASS). Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care. Diagnosis and treatment of cervical radiculopathy from degenerative disorders. https://www.spine.org. Published 2010. Accessed February 27, 2023.

Diagnosis and treatment of lumbar disc herniation with radiculopathy. https://www.spine.org. Published 2012. Accessed February 27, 2023.

  1. Rasouli A, Cuellar J, Kanim L, Delamarter R. Multiple-level lumbar total disk replacement. A prospective clinical and radiographic analysis of motion preservation at 24-72 months. Clin Spine Surg. 2019;32(1):38-42.
  1. UpToDate, Inc. Hyperkyphosis in older persons. https://www.uptodate.com. Updated January 2023. Accessed February 22, 2023.
  2. UpToDate, Inc. Subacute and chronic low back pain: nonpharmacologic and pharmacologic treatment. https://www.uptodate.com. Updated January 2023. Accessed February 22, 2023.
  3. UpToDate, Inc. Subacute and chronic low back pain: nonsurgical interventional treatment. https://www.uptodate.com. Updated January 2023. Accessed February 22, 2023.
  4. UpToDate, Inc. Subacute and chronic low back pain: surgical treatment. https://www.uptodate.com. Updated February 7, 2023. Accessed February 22, 2023.
  5. UpToDate, Inc. Treatment and prognosis of cervical radiculopathy. https://www.uptodate.com. Updated January 17, 2023. Accessed February 22, 2023.
  1. US Food & Drug Administration (FDA). Summary of safety and effectiveness data: ActivL artificial disc. https://www.fda.gov. Published June 11, 2015. Accessed December 29, 2015.
  2. US Food & Drug Administration (FDA). Summary of safety and effectiveness data: Bryan cervical disc. https://www.fda.gov. Published May 12, 2009. Accessed February 4, 2019.
  3. US Food & Drug Administration (FDA). Summary of safety and effectiveness data: M6-C cervical disc. https://www.fda.gov. Published February 6, 2019. Accessed March 9, 2020.
Artificial Intervertebral Disc Replacement Effective Date: 03/23/2023
Revision Date: 03/23/2023
Review Date: 03/23/2023
Policy Number: HUM-0442-023 Page: 16 of 18

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  1. US Food & Drug Administration (FDA). Summary of safety and effectiveness data: MOBI-C cervical disc. https://www.fda.gov. Published August 23, 2013. Accessed January 11, 2015.
  2. US Food & Drug Administration (FDA). Summary of safety and effectiveness data: PCM cervical disc system. https://www.fda.gov. Published October 26, 2012. Accessed January 7, 2013.
  3. US Food & Drug Administration (FDA). Summary of safety and effectiveness data: Prestige LP cervical disc system. https://www.fda.gov. Published July 24, 2014. Accessed January 11, 2015.
  4. US Food & Drug Administration (FDA). Summary of safety and effectiveness data: ProDisc-C total disc replacement. https://www.fda.gov. Published December 17, 2007. Accessed January 7, 2013.
  5. US Food & Drug Administration (FDA). Summary of safety and effectiveness data: ProDisc-L total disc replacement. https://www.fda.gov. Published April 10, 2020. Accessed March 4, 2021.
  6. US Food & Drug Administration (FDA). Summary of safety and effectiveness data: SECURE-C artificial cervical disc. https://www.fda.gov. Published September 28, 2012. Accessed January 7, 2013.
  7. US Food & Drug Administration (FDA). Summary of safety and effectiveness data: Simplify cervical artificial disc. https://www.fda.gov. Published April 1, 2021.
Artificial Intervertebral Disc Replacement Effective Date: 03/23/2023
Revision Date: 03/23/2023
Review Date: 03/23/2023
Policy Number: HUM-0442-023 Page: 17 of 18

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Accessed February 28, 2022.

Artificial Intervertebral Disc Replacement Effective Date: 03/23/2023
Revision Date: 03/23/2023
Review Date: 03/23/2023
Policy Number: HUM-0442-023 Page: 18 of 18

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Appendix A Spondylolisthesis Grades

In this system the slip grade is calculated by determining the ratio between the anteroposterior diameter in the top of the first sacral vertebra and the distance the L5 has slipped anteriorly.

  • Grade I | 25% or less displacement
  • Grade II | Between 25% and 50% displacement
  • Grade III | Between 50% and 75% displacement
  • Grade IV | More than 75% displacement
  • Grade V | L5 vertebra positioned completely below the top of the sacrum