Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3
A 49-year-old female has requested authorization and coverage for 22857 [total disc 
arthroplasty (artificial disc), two-day inpatient stay]. The Health Insurer has 
denied this request and reported that the requested services are investigational for
the treatment of the enrollees medical condition. The physician reviewer found that
total disc replacement is an effective alternative to fusion for lumbar degenerative
disc disease that offers several clinical long-term advantages over single-level 
arthrodesis including sparing adjacent levels from eventual deterioration, long-term
durability without significant loosening or adverse effects from wear debris, motion preservation, fewer re-operations, shorter operating and hospitalization times, 
fewer complications, and better patient reported outcomes in terms of greater 
satisfaction, less pain, and less disability. The FDA approved the use of single 
level lumbar disc replacement in 2006 and expanded approval for two-level lumbar 
disc replacement in 2020, based on good mid-term results with the ProDisc-L implant.
In a meta-analysis including four studies, Zigler and colleagues reported that 
patients with total disc replacement had a significantly greater likelihood of 
Oswestry Disability Index (ODI) success, patient satisfaction, and a significantly 
lower risk of reoperation than fusion patients. Based on a meta-analysis, Li and 
colleagues suggest that total disc replacement could be an alternative treatment for
lumbar degenerative disc disease due to yielding better clinical success including 
patient satisfaction, shorter hospitalization and operative times, less pain, and 
lower complication rates than lumbar fusion. Bai and colleagues report that while 
lumbar fusion is considered the gold standard for treatment of spinal degenerative 
diseases, it may result in adjacent segment degeneration and acquired spinal 
instability while total disc replacement avoids the occurrence of these 
complications. In a meta-analysis of 14 randomized, controlled trials, the authors 
concluded that compared to lumbar fusion, total disc replacement significantly 
improved ODI, visual analog scale (VAS), and short form-36 (SF-36) health 
questionnaire scores, patient satisfaction, overall success, reoperation rate, 
reduced operation time, shortened duration of hospitalization and decreased 
postsurgical complications. Rasouli and colleagues concluded in a clinical and 
radiographic analysis of 159 patients that multilevel lumbar total disc replacement 
demonstrated persistent good results, preservation of motion, and absence of 
adjacent segment disease at a follow-up of six years. While total disc replacement 
surgery may be contraindicated in patients with spinal infection, osteoporosis, 
allergy or sensitivity to implant materials, spondylolisthesis, spinal tumor, 
pregnancy, use of steroids for long duration, previous spinal surgery and the 
morbidly obese, the submitted records do not show that any of these 
contraindications apply to this patient. Current medical literature does not mention
mild, non-degenerative scoliosis as a contraindication to lumbar disc replacement, 
and the patient is not noted as having significant degenerative scoliosis. The 
records did not note abnormal  bone density, spinal instability, or 
spondylolisthesis. The L4-L5 disc was severely involved, with other levels being 
well preserved. Therefore, 22857 [total disc arthroplasty (artificial disc), two-day
inpatient stay] is likely to be more beneficial for treatment of the patient's 
condition than any available standard therapy.