Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total disc arthroplasty (artificial disc), anterior 
approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal 
cord decompression and microdissection); single interspace, cervical (code 22856).  
 
You asked the Plan to pre-approve a total disc arthroplasty (artificial disc), anterior approach, including 
discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression 
and microdissection); single interspace, cervical. You say that a total disc arthroplasty is medically necessary. 
The Plan denied your request. The Plan says a total disc arthroplasty is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a total disc arthroplasty (artificial disc), 
anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or 
spinal cord decompression and microdissection); single interspace, cervical. Our reviewer says that the 
requested total disc arthroplasty is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee was being treated for cervical disc displacement of the cervical 
region; spondylosis without myelopathy/radiculopathy of the cervical region; spinal stenosis of the cervical 
region. The enrollee presented noting she was having left-sided arm pain, but then it switched to the right side. 
The enrollees neck is feeling better. This follow-up was regarding the denial of the artificial disc replacement. 
However, detailed documentation is not evident regarding the current cervical spine objective deficits to 
support this surgical request. The requested surgical levels are not clearly documented; however, appeared to 
be requested at C5-6. The provided CT from April 14, 2023 did not corroborate significant pathology at this 
level, and the adjacent level at C4-5 was documented to have significant pathology. There are limited large-
scale, long-term references showing the safety and efficacy of the requested surgery in this clinical setting. No 
compelling rationale is presented, or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested total disc arthroplasty, in this case, is not medically 
reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a total disc arthroplasty (artificial disc), anterior approach, including discectomy 
with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and 
microdissection); single interspace, cervical have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a total disc arthroplasty (artificial disc), anterior approach, including discectomy with end 
plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); 
single interspace, cervical (code 22856).