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 overturned

The patient is a male. He who underwent a C5-6 (fifth cervical spine vertebra-sixth cervical spine vertebra) ACDF (Anterior Cervical Decompression & Fusion) 10 years ago with residual paresthesias in right first and second digits with urinary urgency and dropping things, according to office visit. There is some biceps weakness on examination. Conservative treatment included physical therapy and medications. Cervical spine x-rays documented C5-6 (fifth cervical spine vertebra-sixth cervical spine vertebra) ACDF (Anterior Cervical Decompression & Fusion) with intact hardware. MRI (magnetic resonance imaging) of the cervical spine documented C4-5 (fourth cervical spine vertebra-fifth cervical spine vertebra) extruded disc flattening cervical cord, fusion at C5-6 (fifth cervical spine vertebra-sixth cervical spine vertebra).

The patient underwent an anterior arthroplasty C4-5 (fourth cervical spine vertebra-fifth cervical spine vertebra) with removal of previous instrumentation performed.

Previous adverse determination occurred as cervical disc arthroplasty when there is a prior fusion at an adjacent level (hybrid construct) is experimental.

Appeal letter stated that this procedure is not hybrid, as C5-6 (fifth cervical spine vertebra-sixth cervical spine vertebra) fusion is solid.

Yes, the health plan should cover the Total Disc Arthroscopy (22856).
Provided medical records document adjacent level (C4-5 [fourth cervical spine vertebra-fifth cervical spine vertebra]) pathology after a C5-6 (fifth cervical spine vertebra-sixth cervical spine vertebra) ACDF (Anterior Cervical Decompression and Fusion) with functionally limiting pain despite appropriate conservative treatment. Recent peer reviewed literature would support this treatment as an alternative to adjacent level fusion, which may limit cervical motion.

The Total Disc Arthroscopy (22856) has similar outcomes to standard treatment of extension of cervical fusion to the adjacent level. The benefit of total disc replacement in a young patient would be maintenance of motion.
Adjacent segment degeneration is common after cervical fusion. The benefits of a total disc replacement (TDR) would be maintenance of motion and may be beneficial in younger patients.

"Artificial cervical disc replacement in patients who have previously undergone cervical fusion surgery appears to be safe, with encouraging early clinical results based on this small case series, but more data from larger numbers of patients with long-term follow-up are needed. Arthroplasty may provide an additional tool for the management of post-fusion adjacent-level cervical disc disease in carefully selected patients." (1)

"TDR [total disc replacement] confers similar surgical and postoperative outcomes to the treatment of ASD [adjacent segment disease] as ACDF [anterior cervical discectomy and fusion]. Both procedures lead to improvement in all performance outcomes." (2)

"At long-term follow-up, CDA [cervical disc arthroplasty] showed better efficacy in terms of clinical outcomes, ROM [range of motion], ASD [adjacent segment disease], and reoperation than ACDF [anterior cervical discectomy and fusion] for treating CDDDs [Cervical Degenerative Disc Diseases]. However, our results require further validation in large-sample and high-quality studies." (3)