Is medical necessity met for total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation, for a patient with spinal stenosis, cervical disc displacement, radiculopathy, and cervicalgia?

Medical Necessity Assessment for Cervical Disc Arthroplasty (CPT 22856)

Medical necessity is NOT currently established for this 38-year-old male requesting cervical disc arthroplasty at C5-6, primarily due to inadequate documentation of conservative treatment failure and missing critical preoperative requirements.

Critical Deficiencies in Current Documentation

Insufficient Conservative Management Documentation

• The patient requires documented failure of at least 6 weeks of comprehensive conservative therapy before cervical disc arthroplasty can be considered medically necessary 1, 2
• Current documentation shows physical therapy from April to June 2025, but lacks specific details regarding:
  • Duration and frequency of therapy sessions
  • Specific therapeutic interventions attempted
  • Patient compliance and response to treatment
  • Trial of NSAIDs or other anti-inflammatory medications
  • Use of narcotic or non-narcotic analgesics
  • Cervical collar immobilization trial 1
• The patient reports he is "not currently using any medications for symptom management," which suggests incomplete conservative treatment trials 1

Missing Required Preoperative Imaging

• Flexion-extension radiographs are absolutely required to definitively rule out segmental instability before proceeding with arthroplasty 1, 2
• The current X-ray report states "No evidence of instability seen on lateral flexion and extension views" but does not provide quantitative measurements of sagittal plane angulation or translation 1
• MCG criteria specifically require absence of sagittal plane angulation >11 degrees and translation >3mm, which are not documented
• Static MRI cannot adequately assess segmental instability 1

Absence of Contraindication Screening

• No documentation addressing inflammatory spondyloarthropathy (ankylosing spondylitis, rheumatoid arthritis) 2
• No documentation regarding osteoporosis status 2
• These are absolute contraindications that must be ruled out before arthroplasty consideration

Clinical Appropriateness When Criteria Are Met

Patient Meets Several Key Indications

• Age 38 years is appropriate for disc arthroplasty, as younger patients may benefit from motion preservation 2, 3
• Single-level C5-6 pathology with moderate to severe foraminal stenosis bilaterally correlates with clinical presentation 1, 2
• Bilateral upper extremity radiculopathy with C5-6 dermatomal distribution (decreased sensation in C5-6 dermatomes, positive Spurling's sign) matches imaging findings 1
• Physically demanding occupation as tugboat engineer with frequent ladder climbing and heavy lifting supports need for motion preservation rather than fusion 2

Imaging Findings Support Surgical Candidacy

• MRI demonstrates bilobed posterior protrusion at C5-6 with moderate central canal stenosis and moderate to severe right neural foraminal narrowing 1
• Moderate left neural foraminal narrowing also present at C5-6
• No severe cord compression or cord edema noted, which is appropriate for arthroplasty candidacy 1

Evidence-Based Outcomes for Cervical Arthroplasty

Superior Outcomes in Appropriate Candidates

• Cervical disc arthroplasty demonstrates equivalent or better outcomes compared to fusion for cervical radiculopathy in properly selected patients 2
• The American College of Neurosurgery recommends cervical disc arthroplasty as an alternative to ACDF for control of neck and arm pain (Class II evidence, strength of recommendation B) 2
• Motion preservation at the affected segment potentially reduces stress on adjacent levels 2

Expected Clinical Improvements

• Studies show approximately 46% improvement in Neck Disability Index scores at 24 months post-arthroplasty 3
• Arm pain improves by approximately 43% and neck pain by 51% at 24 months 3
• Range of motion is maintained at treated levels (mean 12.2° at 24 months) 3
• Patients with shorter symptom duration show better functional results 3

Required Steps to Establish Medical Necessity

Immediate Documentation Requirements

1. Complete and document a minimum 6-week trial of comprehensive conservative management including:

   • Structured physical therapy with specific dates, frequency, and response
   • Trial of NSAIDs with dosing and duration
   • Trial of analgesics (narcotic or non-narcotic) if appropriate
   • Cervical collar immobilization trial
   • Activity modification attempts 1, 2

2. Obtain quantitative flexion-extension radiographs with measurements of:

   • Sagittal plane angulation (must be <11 degrees)
   • Sagittal plane translation (must be <3mm)
   • Formal radiologist interpretation documenting absence of instability 1, 2

3. Document screening for absolute contraindications:

   • Inflammatory spondyloarthropathy (obtain rheumatologic history, consider ESR/CRP if indicated)
   • Osteoporosis (obtain DEXA scan if risk factors present)
   • Confirm no previous cervical surgery at C5-6 level 2

Alternative Consideration: ACDF vs. Arthroplasty

• If the patient ultimately fails conservative management and meets all criteria, both ACDF and arthroplasty are evidence-based options 1, 2
• ACDF provides more rapid relief (within 3-4 months) of arm/neck pain, weakness, and sensory loss with 80-90% success rates for arm pain relief 1
• Arthroplasty offers motion preservation, which may be particularly valuable in this 38-year-old with physically demanding occupation 2, 3
• The choice between ACDF and arthroplasty should be made after complete conservative treatment failure is documented and all preoperative requirements are met

Critical Pitfalls to Avoid

• Do not proceed with arthroplasty without documented 6-week conservative treatment failure - 90% of acute cervical radiculopathy patients improve with conservative management 1
• Do not rely on static imaging alone to rule out instability - dynamic flexion-extension films with quantitative measurements are mandatory 1
• Do not assume absence of contraindications without specific documentation - inflammatory arthropathy and osteoporosis are absolute contraindications that must be actively ruled out 2
• Ensure symptoms correlate with cervical pathology and not lumbar pathology (patient reports bilateral symptoms and left leg numbness, which requires careful evaluation) 1