Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
 
The patient is a 63-year-old female who has undergone very extensive cervical spine surgery dating back 
to 1999. Her first surgery was a C6-7 anterior cervical discectomy and fusion (ACDF). The physician 
reviewer found that the cervical arthroplasty was developed as a motion-preserving device to maintain 
the cervical joint complex biomechanics and attempt to limit the development of adjacent segment 
disease that can occur when treating cervical pathology with an arthrodesis. Although there are 
substantial data supporting the benefits of arthroplasty, it remains controversial as to whether it is 
superior to ACDF. In a recent five-year outcome study of a prospective randomized trial, Johansen and 
colleagues reported similar outcomes between arthroplasty and ACDF over a number of measures in the 
treatment of C6 or C7 radiculopathy. 
 
The indications for a cervical arthroplasty are for cervical disease from C3-4 down to C6-7. A recent 
meta-analysis by Wang and colleagues explored the efficacy of arthroplasty versus ACDF.  Only patients 
with disease from C3-4 to C6-7 were included in the included studies. Although these authors concluded 
that compared to ACDF, arthroplasties resulted in better outcomes over a number of domains, including 
rates of adjacent segment disease, there was no meaningful evaluation of its utility at C7-T1. In general, 
C7-T1 would be a very challenging level at which to perform an arthroplasty given how low it is in the 
cervical spine and the difficulties in visualizing it properly with intraoperative techniques. Excellent 
visualization for perfect implant placement is critical for the best possible outcomes. 
 
Although there are data to suggest that one of the main ways arthroplasty is superior to ACDF is in 
reducing adjacent segment disease, its value in achieving this, especially at C7-T1, is not clear.  This is 
particularly noteworthy in the current patient. This patient has already undergone a C6-7 arthrodesis, 
and T1-2 is a generally immobile level due to the presence of the ribs fixating the thoracic spine. Kelly 
and colleagues evaluated data for over 50,000 patients who underwent ACDF or arthroplasty. 
Subsequent cervical surgery rates were not significantly different between the groups at one, three and 
five years postoperatively. 
 
There are several widely held contraindications for arthroplasty, and this patient appears to harbor 
them. Facet disease is an important contraindication for arthroplasty.  The patients imaging studies 
indicate that at C7-T1 there is remarkable facet disease. The patient underwent facet injections that 
improved her pain reportedly. Arthroplasty is contraindicated with facet disease, and is not thought to 
address it. Spinal deformity is another contraindication for arthroplasty. The patient has numerous 
imaging studies that indicate anterolisthesis at C7-T1. Indeed, this was measured up to 4 mm on x-rays. 
Finally, osteoporosis or poor bone quality is another relative contraindication.  Several of this patients 
imaging studies document osteopenia. 
  The patients provider indicates in his November 2021 note that operating from an anterior approach in 
the spine would be risky with regard to an arthrodesis. This would be no different for an arthroplasty, 
and arthroplasty would offer no benefits in this regard. The provider notes that treatment of C7-T1 
would require a combination anterior/posterior approach. This is debatable.  Finally, over the course of 
the past year, the patient has undergone several surgical procedures on her neck. Her last one was 
performed six weeks prior to the recommendation for the currently pursued surgery. It is arguable that 
the patient has not completely recovered from her other surgeries to allow for making a determination 
on another. Finally, the documented symptoms the patient reports are quite vague (neck pain, hand 
pain, right jaw symptoms, scapula pain, chest tightness and shortness of breath, and coldness in the 
fingertips). It is not likely that an arthroplasty at C7-T1 would address these. Based on the submitted 
documentation, the requested total disc arthroplasty C7-T1 anterior approach discectomy end plate 
preparation is not medically necessary for the treatment of this patient.