Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Herniated Disc, Cervical
Treatment: Total Disc Arthroscopy (22856)
The insurer denied the Total Disc Arthroscopy (22856)
The denial is upheld

The patient is a male. The patient had surgery for anterior disc arthroplasty of C4-5 (fourth cervical spine vertebra-fifth cervical spine vertebra). This included removal of previous instrumentation. The patient had a previous anterior cervical fusion of C5-6 (fifth cervical spine vertebra-sixth cervical spine vertebra) and x-ray reports indicated this to be a solid fusion.

The patient presented with complaints of neck pain and right upper extremity paresthesias for the prior two to three weeks. The patient was also having some urinary urgency. The physical exam showed 5/5 strength of the upper extremities. There was normal sensation and normal reflexes were noted. There is negative Hoffmann sign.

The patient had an MRI (magnetic resonance imaging) of the cervical spine showing a right foraminal disc herniation at C4-5 (fourth cervical spine vertebra-fifth cervical spine vertebra). The patient was continued on physical therapy. The patient had persistent symptoms and was recommended for a cervical disc arthroplasty of C4-5 (fourth cervical spine vertebra-fifth cervical spine vertebra).

The patient was informed that insurance company would not pay for the disc arthroplasty due to the exposure mental nature. The patient wished to proceed with the disc arthroplasty anyway. The patient was evaluated and had resolution of the right arm symptoms after the surgery. X-ray showed the implant to be in stable position with good movement on flexion-extension. The MRI (magnetic resonance imaging) report showed a fused level at C5-6 (fifth cervical spine vertebra-sixth cervical spine vertebra) with an extruded disc fragment at C4-5 (fourth cervical spine vertebra-fifth cervical spine vertebra) into the right neural foramina. This is to review for the surgery for the disc arthroplasty of C4-5 (fourth cervical spine vertebra-fifth cervical spine vertebra).

No, the health plan should not cover the Total Disc Arthroscopy (22856).
The patient has been recommended for a disc arthroplasty adjacent to a previous fusion. The use of the disc arthroplasty adjacent to the fusion would be considered experimental/investigational. There are studies showing that this hybrid procedure is safe and is evidenced to be effective. However, this is an off-label use of the device according to the FDA (United States Food and Drug Administration) prescribing guidelines. Furthermore, there is insufficient data in the scientific literature to support the long-term efficacy of this treatment especially with the altered biomechanics adjacent to a fusion level. Thus, the treatment should not be covered since it is considered experimental/investigational.

No, the total Disc Arthroscopy (22856) is not more beneficial than any standard treatment for the insured's condition or disease.
The standard treatment options would be for an extension of the cervical fusion to the C4-5 (fourth cervical spine vertebra-fifth cervical spine vertebra) level. This is well-studied in the scientific literature and would be considered safe, effective, and standard of care for the patient's condition. The treatment with the disc arthroplasty has not been shown in the long-term literature to be more effective than fusion surgery. Thus, the treatment would not be considered standard of care for this diagnosis.