Is cervical artificial disc replacement medically necessary for a patient with cervical radiculopathy and degenerative spondylopathy of the cervical spine?

Cervical Artificial Disc Replacement is NOT Medically Necessary in This Case

This patient's requested cervical artificial disc replacement at C4-5 and C5-6 should be denied because she has a recent postoperative infection (3 months ago), is requesting a hybrid construct (disc replacement adjacent to her existing C6-7 fusion) which is not FDA-approved, and lacks the required flexion-extension radiographs to definitively rule out segmental instability—an absolute FDA requirement for disc arthroplasty. 1, 2

Critical Contraindications Present

Recent Postoperative Infection

• Recent postoperative infection represents a significant contraindication to artificial disc placement, as it carries an unacceptable risk of recurrent infection and implant failure. 1
• This patient underwent ACDF at C6-7 in June 2025 and was found to have infection requiring 6 weeks of antibiotics, with the current request dated November 2025—only 5 months post-infection. 1
• There is no documentation of complete infection resolution with normal inflammatory markers (ESR, CRP), which is required before considering any implant placement. 1

Hybrid Construct Not FDA-Approved

• Adjacent level disease after recent fusion is a contraindication for artificial disc replacement, as it is not FDA-approved and lacks long-term outcome data. 1
• All FDA-approved cervical disc devices are indicated for levels C3-C7, but hybrid surgery (combining disc replacement with adjacent fusion) is not FDA-approved. 2
• The patient is requesting disc replacement at C4-5 and C5-6 immediately adjacent to her existing C6-7 fusion, creating a hybrid construct. 2

Missing Required Documentation

• Flexion-extension radiographs are required to definitively rule out segmental instability before proceeding with arthroplasty. 1
• Static MRI cannot adequately assess segmental instability, and flexion-extension films are necessary. 1
• The additional clinical information states "no segmental instability present on the imaging done," but this appears to reference static MRI only—not the required dynamic flexion-extension radiographs. 1

What IS Medically Necessary: ACDF with Instrumentation

Evidence Supporting ACDF Over Arthroplasty

• ACDF is specifically indicated for patients with moderate to severe foraminal stenosis when conservative management has failed, with an 80-90% success rate for arm pain relief in cervical radiculopathy. 1
• The patient has moderate left foraminal stenosis at C5-6 (increased from prior) and moderate canal stenosis at C5-6, meeting the "moderate to severe or severe" threshold required by policy. 1
• Her excellent diagnostic response to injection (80% relief) confirms that the C5-6 level is the pain generator. 1

Instrumentation is Indicated for 2-Level Disease

• Anterior cervical plating (instrumentation) is recommended for 2-level cervical disc degeneration to improve arm pain (Class II evidence, strength of recommendation C). 1
• For multilevel fusions, instrumentation provides greater stability and improved outcomes. 1
• The addition of a cervical plate reduces the risk of pseudarthrosis and graft problems, and helps maintain lordosis. 1

Conservative Treatment Requirements Met

• The patient has completed 6 weeks of conservative therapy including Flexeril, gabapentin, oxycodone, and prednisone since June 2025. 1
• She has undergone epidural steroid injection with excellent diagnostic response (80% relief). 1
• 90% of acute cervical radiculopathy patients improve with conservative management, but surgery is recommended for persistent symptoms despite adequate conservative therapy. 1
• This patient has persistent left C6 radiculopathy with weakness, numbness, and functional impairment (dropping things, decreased dexterity) despite 5 months of treatment. 1

Clinical Correlation Confirmed

• Her symptoms (left-sided pain radiating to biceps and thumb, C6 dermatomal distribution, weakness, numbness) directly correlate with the C5-6 pathology on MRI. 1
• Physical examination confirms weakness and numbness. 1
• MRI demonstrates moderate left foraminal stenosis at C5-6 (increased from prior) and moderate canal stenosis. 1

Recommended Path Forward

Approve 2-level ACDF with instrumentation at C4-5 and C5-6 (CPT 22552,22585,22845,22846) ONLY after:

1. Obtain flexion-extension cervical radiographs to definitively rule out segmental instability (required even for ACDF to ensure surgical planning is appropriate). 1

2. Document complete resolution of prior infection with normal inflammatory markers (ESR, CRP) before any surgical intervention. 1

3. Confirm that C4-5 level meets moderate to severe stenosis criteria on imaging, as the current documentation primarily describes C5-6 pathology. 1

Common Pitfalls to Avoid

• Do not approve arthroplasty based on static MRI alone—dynamic flexion-extension films are mandatory to exclude instability. 1
• Do not approve hybrid constructs—they are not FDA-approved and lack long-term safety data. 2
• Do not proceed with any implant surgery without documented infection clearance—the 3-month timeframe since infection is insufficient without laboratory confirmation. 1
• Do not approve surgery at levels that fail to meet moderate-to-severe stenosis criteria—mild stenosis does not justify surgical intervention. 1