Is a cervical artificial disc replacement (Cerv Artific Discectomy) medically necessary for a patient with cervical radiculopathy who has failed conservative treatment and has no radiologic evidence of segmental instability?

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Medical Necessity Determination for Cervical Artificial Disc Replacement (CPT 22856)

Cervical artificial disc replacement at C4-5 and C5-6 is NOT medically necessary for this patient because there is no documented radiologic evidence of segmental instability, which is an absolute contraindication per FDA-approved device criteria and established guidelines.

Critical Missing Requirement: Segmental Instability Assessment

The absence of documented radiologic evidence regarding segmental instability is a disqualifying factor for cervical disc arthroplasty. 1

  • FDA-approved cervical disc prostheses (ProDisc-C, ProDisc-C Vivo, ProDisc-C SK) explicitly require that "there is no radiologic evidence of segmental instability" as a mandatory inclusion criterion 2
  • The request states the provider is "UNSURE IF PATIENT HAS RADIOLOGIC EVIDENCE OF SEGMENTAL INSTABILITY" - this uncertainty alone disqualifies the patient from artificial disc replacement 1
  • Flexion-extension radiographs are required to definitively rule out segmental instability before proceeding with arthroplasty 3

Additional Contraindications Present

Recent Infection History

This patient has a documented recent postoperative infection (June 2025) requiring 6 weeks of IV antibiotics, which represents a significant contraindication to artificial disc placement. 1

  • The patient underwent ACDF at C6-7 in June 2025 and developed a postoperative infection 1
  • Placing a motion-preserving implant in a patient with recent spinal infection carries unacceptable risk of recurrent infection and implant failure 2
  • The timeline from infection treatment (completed approximately August 2025) to proposed surgery (November 2025) is only 3 months - insufficient time to ensure complete resolution 1

Adjacent Level Disease After Recent Fusion

The patient now presents with new C6 radiculopathy "since surgery" at an adjacent level (C5-6) to her recent C6-7 fusion, which fundamentally changes the surgical indication. 1

  • MRI shows "degenerative spondylopathy most prominent at C5-C6 where there is moderate canal stenosis and moderate left foraminal stenosis, which is increased from prior" 1
  • This represents adjacent segment disease developing within 4-5 months of the index fusion 3
  • Performing artificial disc replacement adjacent to a recent fusion site (hybrid construct) is not FDA-approved and lacks long-term outcome data 2

Appropriate Alternative: Anterior Cervical Decompression and Fusion

ACDF at C5-6 (and potentially C4-5 if clinically indicated) is the medically necessary procedure for this patient, not artificial disc replacement. 3, 1

Why ACDF is Indicated:

  • Moderate to severe stenosis documented: MRI confirms "moderate canal stenosis and moderate left foraminal stenosis" at C5-6, meeting the severity threshold for surgical intervention 1
  • Clinical correlation present: Left C6 radiculopathy with weakness, numbness, and 80% relief from diagnostic injection directly correlates with C5-6 pathology 3, 1
  • Failed conservative management: Patient has undergone 5+ months of conservative treatment including Flexeril, gabapentin, oxycodone, and prednisone since June 2025 1, 4
  • Functional impairment: Patient reports dropping things, decreased dexterity, and pain radiating to left biceps and thumb, indicating significant functional deficit 1, 4

Evidence Supporting ACDF Over Arthroplasty:

  • ACDF provides 80-90% success rates for arm pain relief in cervical radiculopathy 3, 1
  • Anterior cervical plating is recommended for 2-level disease to improve arm pain and reduce pseudarthrosis risk 3
  • ACDF is specifically indicated for patients with moderate to severe foraminal stenosis when conservative management has failed 1
  • The Journal of Neurosurgery reports 90.9% functional improvement following anterior cervical decompression for radiculopathy 3, 1

Addressing the C4-5 Level

The medical necessity for C4-5 intervention is questionable based on available documentation. 1

  • No specific imaging findings at C4-5 are documented in the provided MRI report 1
  • Clinical symptoms (C6 radiculopathy) do not correlate with C4-5 pathology 3, 1
  • Performing fusion at a level without documented moderate-to-severe stenosis is not supported by guidelines 1
  • If C4-5 intervention is considered necessary, the surgeon must document specific imaging findings showing moderate-to-severe stenosis and clinical correlation 3, 1

Critical Documentation Deficiencies

Before ANY cervical surgery can be approved, the following must be obtained:

  1. Flexion-extension cervical spine radiographs to definitively rule out segmental instability at all proposed surgical levels 3
  2. Detailed C4-5 imaging findings from the MRI report to justify intervention at this level 3, 1
  3. Documentation of infection resolution including follow-up inflammatory markers (ESR, CRP) and clinical assessment confirming no ongoing infection 1
  4. Specific conservative treatment timeline with dates, frequency, and response to each modality (currently documented as "since June" which is adequate at 5+ months, but specifics strengthen the case) 1, 4

Common Pitfalls to Avoid

  • Do not proceed with artificial disc replacement in the setting of recent infection - this represents an absolute contraindication regardless of other factors 2
  • Do not perform hybrid constructs (disc replacement adjacent to fusion) without FDA approval - this is considered investigational 2
  • Do not assume stability without flexion-extension films - static MRI cannot adequately assess segmental instability 3
  • Do not operate on levels without documented moderate-to-severe stenosis - mild stenosis does not meet surgical thresholds 1

Recommended Approval Path

Approve ACDF at C5-6 (CPT 22551,22552 if applicable, 22845 for instrumentation) contingent on:

  1. Flexion-extension radiographs confirming no segmental instability 3
  2. Documentation of complete infection resolution with normal inflammatory markers 1
  3. Detailed imaging report confirming moderate-to-severe stenosis at C5-6 (already documented) 1

Deny artificial disc replacement (CPT 22856) due to:

  1. Absence of documented stability assessment (absolute contraindication) 1, 2
  2. Recent postoperative infection history (relative contraindication) 1
  3. Adjacent level to recent fusion (not FDA-approved for hybrid construct) 2

Require additional documentation before considering C4-5 intervention:

  1. Specific MRI findings at C4-5 showing moderate-to-severe stenosis 3, 1
  2. Clinical correlation between symptoms and C4-5 pathology 3, 1

References

1
Guideline

Cervical Radiculopathy Diagnosis and Treatment

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

3
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

4
Research

Cervical radiculopathy: epidemiology, etiology, diagnosis, and treatment.

Journal of spinal disorders & techniques, 2015

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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