Artificial Intervertebral Disc

Medical Policy: 07.01.03 
Original Effective Date: February 2007 
Reviewed: May 2008 
Revised:  

This policy applies to all products unless specific contract limitations, exclusions or exceptions apply. Please refer to the member's coverage manual for benefit availability. Managed care guidelines related to referral authorization, and precertification of inpatient hospitalization, home health, home infusion and hospice services apply.

Description: 

When conservative treatment of degenerative disc disease fails, a common surgical approach is spinal fusion; over 200,000 spinal fusions are performed each year.  However, the outcomes of spinal fusion have been controversial over the years, in part due to the difficulty in determining whether a patient's back pain is related to degenerative disc disease and in part due to the success of the procedure itself.  In addition, spinal fusion alters the biomechanics of the back, potentially leading to premature disc degeneration at adjacent levels, a particular concern for younger patients. 

As an alternative, a variety of artificial intervertebral discs have been investigated over the past 30 years as an alternative to fusion. This approach, also referred to as total disc replacement or spinal arthroplasty, is intended to maintain motion at the operative level once the damaged disc has been removed, and to maintain the normal biomechanics of the adjacent vertebrae. 

Policy: 


Artificial intervertebral discs are considered investigational for treatment of disorders of the cervical and lumbar spine.

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Procedure Codes and Billing Guidelines: 

To report provider services, use appropriate CPT* codes, Alpha Numeric, (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
  • CPT 22856 Total disc arthroplasty, anterior approach,cervical
  • CPT 0092T Each additional interspace 
  • CPT 22864 Removal of total disc arthroplasty, anterior approach, single interspace; cervical
  • CPT 0095T Each additional interspace 
  • CPT 22861 Revision of total disc arthroplasty, anterior approach, cervical
  • CPT 0098T Each additional interspace
  • CPT 22857 Total disc arthroplasty (artificial disc,) anterior approach, including discectomy to prepare interspace (other than for decompression), lumbar, single interspace
  • CPT 22862 Revision including replacement of total disc arthroplasty (artificial disc) anterior approach, lumbar, single interspace
  • CPT 22865 Removal of total disc arthroplasty (artificial disc), anterior approach, lumbar, single interspace
  • CPT 0163T Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), lumbar, each additional interspace
  • CPT 0164T Removal of total disc arthroplasty, anterior approach, lumbar, each additional interspace
  • CPT 0165T Revision of total disc arthroplasty, anterior approach, lumbar, each additional interspace 

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Selected References: 

  • The Medical Policy Reference Manual (MPRM) developed by the Blue Cross and Blue Shield Association Health Management Systems, based on the Technology Evaluation Center (TEC) criteria.
  • Lemaire JP, Skalli W, Lavaste F et al. Intervertebral disc prosthesis. Results and prospects for the year 2000. Clin Orthop 1997; 337:64-76.
  • Hochschuler SH, Ohnmeiss DD, Guyer RD et al.  Artificial disc: preliminary results of a prospective study in the United States. Eur Spine J 2002; 11(suppl 2):S106-10.
  • ECRI, Technology Assessment Resources Guide for Emerging Technologies.  Artificial intervertebral disc, replacement for degenerative disc disease. March 2004.
  • Blue Cross Blue Shield Association Technology Evaluation Center (TEC). 2005. Artificial Vertebral Disc Replacement. TEC Assessments, 20(1):1-18. 
  • TARGET [database online]. Plymouth Meeting (PA): ECRI; November 2006; Target Report 852. Artificial intervertebral disc replacement for lumbar disc disease. Available: http://www.ecri.org.
  • Sasso RC, Foulk DM, Hahn M. Prospective, randomized trial of metal-on-metal artificial lumbar disc replacement: initial results for treatment of discogenic pain. Spine 2008 Jan 15;33(2):123-31.
  • Sasso RC, Smucker JD, Hacker RJ et al. Artificial disc versus fusion: a prospective, randomized study with 2-year follow-up on 99 patients. Spine 2007 Dec 15;32926):2933-40; discussion 2941-2.
  • Nabhan A, Ahlhelm F, Shariat K et al. The ProDisc-C prosthesis: clinical and radiological experience 1 year after surgery. Spine. 2007 Aug 15;32(18):1935-41.
  • Blue Cross Blue Shield Association Technology Evaluation Center (TEC). 2008. Artificial Intervertebral Disc Arthroplasty for Treatment of Degenerative Disc Disease of the Cervical Spine. TEC Assessments, 22(12):1-24.
  • Blue Cross Blue Shield Association Technology Evaluation Center (TEC). 2007. Artificial Lumbar Disc Replacement. TEC Assessments; 22(2):1-24.

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New information or technology that would be relevant for Wellmark to consider when this policy is next reviewed may be submitted to:

Wellmark Blue Cross and Blue Shield
Medical Policy Analyst
Station 304
636 Grand Ave
Des Moines, Iowa 50309

*Current Procedural Terminology © 2009 American Medical Association. All Rights Reserved.

Wellmark medical policies address the complex issue of technology assessment of new and emerging treatments, devices, drugs, etc.   They are developed to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Wellmark medical policies contain only a partial, general description of plan or program benefits and do not constitute a contract. Wellmark does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies may be updated and therefore are subject to change without notice.