Is a cervical artificial disc replacement (CERV ARTIFIC DISKECTOMY) medically necessary for a patient with upper neck pain and cervical radiculopathy at C6-C7 level?

Medical Necessity Determination: Cervical Artificial Disc Replacement NOT Supported

Based on the insurance criteria and current clinical evidence, cervical artificial disc replacement (CPT 22856) at C6-C7 is NOT medically necessary for this patient at this time due to the absence of required imaging studies and inadequate documentation of conservative treatment duration.

Critical Missing Requirements

Imaging Studies Required But Absent

The Aetna policy explicitly requires imaging studies (CT or MRI) demonstrating specific findings that are completely absent in this case 1, 2:

• No imaging has been performed - The request states "NO IMAGING" which fails to meet the fundamental requirement for nerve root or spinal cord compression visualization 1, 2
• Cannot confirm moderate-to-severe stenosis - The policy requires central/lateral recess or foraminal stenosis graded as "moderate, moderate to severe or severe" (not mild or mild to moderate), which cannot be assessed without imaging 1
• Cannot rule out segmental instability - The policy requires radiologic evidence that there is NO segmental instability, which cannot be determined without imaging 1
• Cannot confirm nerve compression at corresponding level - While the patient has clinical radiculopathy symptoms, imaging must demonstrate nerve root or spinal cord compression at the level corresponding with clinical findings 1, 2

The American College of Radiology (ACR) 2025 guidelines clearly state that MRI of the cervical spine without contrast is the appropriate initial imaging study for patients with cervical radiculopathy characterized by neck pain radiating to the arm with neurologic symptoms 1, 2.

Conservative Treatment Duration Uncertain

The policy requires at least 6 weeks of documented conservative therapy, but the request indicates "UNKNOWN DURATION" of conservative treatments 1:

• The patient lists NSAIDs, rest, and facet injections as treatments tried, but no timeline is provided
• The patient states he "probably waited three years too long to seek treatment," suggesting chronic symptoms but unclear when active treatment began
• Without documented 6-week minimum of conservative therapy, this criterion is UNDETERMINED and cannot support approval 1

The ACR guidelines note that 75-90% of cervical radiculopathy patients achieve symptomatic relief with nonoperative conservative therapy, making adequate conservative treatment trial essential before surgical intervention 1, 2.

Clinical Presentation Analysis

Symptoms Suggest Mixed Pathology

The patient's presentation indicates two distinct pain generators that complicate the surgical indication 1:

• Upper cervical facet pain (C3-4): Bilateral upper neck and muscle pain with headache-like symptoms, temporarily relieved by facet injections, suggesting facetogenic pain 1
• Lower cervical radiculopathy (C6-7): The disc disorder with radiculopathy at C6-7 may warrant intervention, but this is only ONE of the patient's pain sources 1, 2

Critical concern: Cervical disc replacement at C6-7 will NOT address the C3-4 facet arthrosis pain, which appears to be a significant component of the patient's disability 1. The patient describes "upper neck" pain affecting "both sides and the muscles" with radiation creating "headache-like" sensations - this clinical pattern is more consistent with facetogenic pain than C6-7 radiculopathy 1.

Radiculopathy Pattern Unclear

The request does not specify:

• Which nerve root distribution is affected (C7 vs C8)
• Presence or absence of motor weakness
• Dermatomal sensory loss pattern
• Reflex changes

Without imaging correlation, it is impossible to confirm that C6-7 pathology corresponds to the clinical symptoms 1, 2.

Required Next Steps Before Surgical Consideration

1. Obtain MRI Cervical Spine Without Contrast (MANDATORY)

The ACR designates this as the most appropriate initial imaging for cervical radiculopathy 1, 2:

• Must demonstrate nerve root or spinal cord compression at C6-7 level corresponding with clinical findings 1, 2
• Must grade stenosis severity (moderate, moderate-to-severe, or severe required for approval) 1
• Must rule out segmental instability 1
• Must exclude other pathology (tumor, infection, myelopathy) 1, 2

2. Document Adequate Conservative Treatment (MANDATORY)

Minimum 6 weeks of documented conservative therapy must include 1:

• Physical therapy with specific dates and duration
• Medication management (NSAIDs, muscle relaxants, neuropathic pain medications)
• Activity modification
• Cervical epidural steroid injections may be considered if appropriate

Exception: The policy allows waiving conservative treatment for progressive motor weakness or myelopathy, which is NOT documented in this case 1, 2.

3. Consider C3-4 Facet Ablation First

Given the patient had temporary relief from C3-4 facet injections, radiofrequency ablation at this level should be strongly considered as it may address a significant portion of his disability without surgery 1.

Why Imaging Cannot Be Bypassed

The ACR 2025 guidelines emphasize that MRI alone should not be used to diagnose symptomatic cervical radiculopathy and should always be interpreted in combination with clinical findings, but conversely, clinical findings alone are insufficient without imaging confirmation 1:

• Physical examination has limited accuracy for diagnosing cervical radiculopathy 1
• High rate of abnormalities detected in asymptomatic patients means imaging findings must correlate with symptoms 1
• Surgical planning requires precise anatomic localization that only imaging can provide 1, 2

Recommendation Algorithm

DENY the current request for cervical artificial disc replacement and require:

1. MRI cervical spine without contrast to document nerve compression, stenosis severity, and rule out instability 1, 2
2. Documentation of at least 6 weeks of conservative treatment with specific dates and modalities 1
3. Consideration of C3-4 radiofrequency ablation given positive response to diagnostic facet injections 1
4. Resubmission with complete documentation once imaging and conservative treatment criteria are met 1

If imaging demonstrates appropriate pathology and conservative treatment is adequately documented, then reconsider surgical candidacy - but cervical disc replacement may still not be the optimal procedure if significant facetogenic pain persists 1, 2.