Is total disc replacement at C3-4 and C5-6 medically necessary for a 51-year-old female with cervical degenerative disc disease, non-contiguous disc herniations, and unknown osteoporosis status?

Medical Necessity Determination: Total Disc Replacement at C3-4 and C5-6

Total disc replacement at non-contiguous levels C3-4 and C5-6 does NOT meet medical necessity criteria and should be DENIED based on the MCG guideline requirement for "1 or 2 contiguous-level artificial disks." 1

Critical Criterion Failure

The fundamental disqualifying factor is that C3-4 and C5-6 are non-contiguous levels (separated by C4-5), which explicitly violates the MCG criterion requiring placement of "1 or 2 contiguous-level artificial disks." 1 This is an absolute contraindication that cannot be overcome by meeting other criteria.

FDA-Approved Indications Do Not Support This Request

• All FDA-approved cervical artificial discs are indicated for levels C3 to C7, but FDA approval for 2-level cervical total disc replacement specifically requires contiguous levels 2
• Hybrid surgery (combining disc replacement with fusion at non-contiguous levels) is not FDA approved 2
• The evidence base for cervical disc arthroplasty comes exclusively from trials involving either single-level or 2-level contiguous disease 3, 4

Additional Concerns Regarding Osteoporosis Status

The unknown osteoporosis status represents a second critical barrier to approval, as the MCG criteria explicitly require "No osteoporosis." 1

Why This Matters Clinically

• This 51-year-old female has multiple risk factors warranting osteoporosis screening: post-menopausal age range, history of gastric sleeve surgery (malabsorption risk), and chronic vitamin D supplementation (suggesting prior deficiency) 1
• Osteoporosis is an absolute contraindication to cervical disc arthroplasty because adequate bone quality is essential for endplate integrity and device fixation 5
• A DEXA scan must be obtained and documented as normal before any cervical disc replacement can be considered medically necessary 1

Alternative Medically Necessary Approach

The appropriate surgical intervention for this patient is anterior cervical discectomy and fusion (ACDF) at both levels, which is supported by strong evidence and meets all clinical criteria. 6

Why ACDF is the Correct Procedure

• ACDF provides 80-90% success rates for arm pain relief in cervical radiculopathy with disc herniation and spinal cord compression 1
• The patient has failed >6 weeks of conservative treatment (6 years of symptoms with physical therapy, multiple injections, NSAIDs alternatives, and chiropractic care) 6
• Clinical correlation is excellent: 4/5 strength deficits in left deltoids and triceps correspond to C5-6 pathology, while bilateral symptoms and head tingling suggest C3-4 cord compression 6
• MRI demonstrates large disc herniations at both levels flattening the spinal cord, which represents moderate-to-severe pathology meeting surgical thresholds 1

Evidence Supporting 2-Level Non-Contiguous ACDF

• Anterior cervical plating (instrumentation) is specifically recommended for 2-level cervical disc degeneration to improve arm pain and reduce pseudarthrosis risk 6, 1
• For 2-level disease, anterior cervical plating reduces pseudarthrosis risk from 4.8% to 0.7% and improves fusion rates from 72% to 91% 1
• ACDF provides more rapid relief (within 3-4 months) of arm/neck pain, weakness, and sensory loss compared to continued conservative treatment 1

Specific Rationale for Denial

MCG Criterion Analysis

1. Age 18 years or older: MET (51 years old)
2. Cervical degenerative disk disease between C3 and C7, and placement of 1 or 2 contiguous-level artificial disks is planned: NOT MET - C3-4 and C5-6 are non-contiguous
3. Symptoms corresponding to level(s): MET (radiculopathy, cord compression)
4. Failure of nonoperative treatment: MET (>6 years of conservative care)
5. No evidence of cervical instability: MET (retrolisthesis <3mm at both levels)
6. No anatomic deformity or malignancy: MET
7. No inflammatory spondyloarthropathy: MET
8. No osteoporosis: UNKNOWN/NOT MET - never tested

Clinical Decision Algorithm

When evaluating cervical disc replacement requests:

1. First, verify levels are contiguous - if non-contiguous, disc replacement is contraindicated regardless of other factors 2
2. Second, confirm osteoporosis screening is negative - if unknown or positive, disc replacement is contraindicated 1
3. Third, assess for other absolute contraindications: facet arthropathy, significant kyphosis, prior fusion at adjacent levels, active infection 5, 2
4. Only if all three steps pass, then evaluate clinical appropriateness (symptoms, conservative treatment failure, imaging correlation) 1

Common Pitfalls to Avoid

• Do not approve disc replacement simply because the patient "meets most criteria" - the contiguous-level requirement is absolute, not negotiable 2
• Do not assume osteoporosis is absent without documentation - the burden of proof is on demonstrating normal bone density, especially in at-risk populations 1
• Do not confuse "2-level disease" with "2-level contiguous disease" - FDA approval and evidence base apply only to contiguous levels 2, 3, 4

Recommended Approval Path

Approve CPT 22551 (Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2) x2 levels with CPT 22845 (Anterior instrumentation; 2 to 3 vertebral segments) for C3-4 and C5-6 ACDF with anterior cervical plating. 6, 1

This approach addresses the pathology at both non-contiguous levels, meets all evidence-based criteria, and avoids the contraindications that disqualify disc replacement in this clinical scenario.