Medical Necessity Determination for C5-C6 Artificial Disc Replacement
Primary Recommendation: Artificial Disc Replacement is NOT Medically Necessary
This patient should receive anterior cervical discectomy and fusion (ACDF) at C3-C4, C4-C5, and C5-C6 with anterior cervical plating, NOT artificial disc replacement at C5-C6. The presence of cervical myelopathy with multilevel spinal stenosis makes this patient a poor candidate for arthroplasty, and the mixed surgical approach (osteophyte excision at multiple levels with arthroplasty at only one level) creates a biomechanically inconsistent construct 1.
Critical Disqualifying Factors for Artificial Disc Replacement
Cervical Myelopathy Contraindication
- The presence of cervical myelopathy with spinal stenosis at multiple levels makes this patient a poor candidate for artificial disc replacement, as the evidence supporting its use in myelopathy is limited 1.
- Cervical myelopathy represents spinal cord compression requiring decompression to prevent permanent neurological injury 1.
- While some research suggests CDA can be used for myelopathy 2, 3, the guideline evidence prioritizes fusion for multilevel myelopathic disease 1.
Multilevel Pathology Requiring Uniform Treatment
- Multilevel pathology requiring surgical intervention at C3-C4, C4-C5, and C5-C6 necessitates anterior osteophyte excision at all three levels 1.
- A mixed surgical approach involving osteophyte excision at C3-C4 and C4-C5 with arthroplasty at only C5-C6 creates a biomechanically inconsistent construct 1.
- Advanced spondylotic changes, including large osteophytes causing esophageal compression, represent more severe degenerative disease than typical arthroplasty candidates 1.
Policy Criteria Not Met
- The insurance policy requires FDA-approved devices for 2 contiguous levels, but the specific brand is unknown, making medical necessity determination impossible 4.
- The patient's age (48 years) falls within acceptable ranges for Mobi-C (21-67 years), Prestige LP (21-78 years), and Simplify (under 70 years), but without knowing the specific device, compliance cannot be confirmed 4.
- Unknown osteoporosis status represents a critical barrier, as policy explicitly requires "No osteoporosis" for cervical disc replacement 4.
Medically Appropriate Surgical Approach: Multilevel ACDF
Recommended Procedure
- Perform anterior cervical discectomy and fusion with instrumentation at C3-C4, C4-C5, and C5-C6, including complete anterior osteophyte excision, neural decompression, interbody graft placement, and anterior cervical plating for stability 1.
- Multilevel fusion with plating is specifically recommended for 2-level cervical disc degeneration to improve arm pain, and this patient requires 3-level surgery 1.
- ACDF addresses all pathology uniformly and provides necessary stability 1.
Evidence Supporting ACDF Over Arthroplasty
- ACDF is effective for cervical radiculopathy, with good or better outcomes in approximately 90% of patients using Odom's criteria 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% 5.
- ACDF provides 80-90% success rates for arm pain relief in cervical radiculopathy with disc herniation and spinal cord compression 4.
- Motor function recovery occurs in 92.9% of patients, with long-term improvements maintained over 12 months 5.
Instrumentation Necessity
- The addition of cervical plating is recommended to reduce pseudarthrosis risk and maintain lordosis, particularly important in multilevel constructs 1.
- Anterior cervical plating is specifically recommended for 2-level cervical disc degeneration to improve arm pain and reduce pseudarthrosis risk 4.
Clinical Justification for Surgical Intervention
Conservative Management Failure
- The patient has failed conservative management, including multiple rounds of physical therapy, anti-inflammatory medications (naproxen), steroids, muscle relaxants (methocarbamol), neuropathic pain medications (amitriptyline, Lyrica), opioids (oxycodone), radiofrequency ablation (C2-C4 RFA with 80% relief for 7-8 months), and epidural steroid injection (L5-S1 ESI with 90% relief for 1 month) 1.
- The patient meets the 6-week conservative therapy requirement before surgical intervention 5.
- Progressive neurological symptoms warrant surgical intervention 1.
Specific Clinical Indications Met
- Worsening dysphagia and voice changes from esophageal compression by large anterior osteophytes at C3-C4, C4-C5, and C5-C6 require anterior decompression 1.
- C5-C6 radiculopathy persists despite conservative management, with severe bilateral foraminal stenosis on MRI 1.
- Cervical myelopathy diagnosis requires decompression to prevent permanent neurological injury 1.
- Advanced imaging (MRI and CT) confirms moderate to severe stenosis at multiple levels, meeting policy criteria for surgical intervention 5.
Policy Compliance Analysis
CPT Code 63081 and 63082 (Vertebral Body Removal): APPROVED
- Cervical laminectomy and anterior discectomy with fusion criteria are met: all other sources of pain ruled out, signs/symptoms of neural compression present, advanced imaging shows moderate to severe stenosis, 6+ weeks of conservative therapy failed, and activities of daily living are limited 1.
- Anterior cervical decompression is specifically indicated for symptomatic cervical radiculopathy resulting from cervical spondylosis with foraminal compromise 1.
CPT Code 22856 (Artificial Disc Replacement): DENIED
- The specific brand of artificial cervical disc is unknown, making it impossible to confirm FDA approval and age-range compliance 4.
- Cervical myelopathy with multilevel stenosis is a relative contraindication to artificial disc replacement based on guideline evidence 1.
- Unknown osteoporosis status is an absolute contraindication, as adequate bone quality is essential for endplate integrity and device fixation 4.
- The mixed surgical approach (osteophyte excision at C3-C4 and C4-C5 with arthroplasty at C5-C6) is biomechanically inconsistent and not supported by guidelines 1.
Common Pitfalls to Avoid
Premature Arthroplasty in Myelopathy
- Do not perform artificial disc replacement in patients with cervical myelopathy and multilevel stenosis, as the evidence supporting its use in this population is limited 1.
- CDA is more appropriate for isolated radiculopathy without myelopathy 6.
Incomplete Preoperative Workup
- A DEXA scan must be obtained and documented as normal before any cervical disc replacement can be considered medically necessary 4.
- Flexion-extension radiographs are required to definitively rule out segmental instability before proceeding with arthroplasty 5.
Biomechanically Inconsistent Constructs
- Avoid mixing fusion and arthroplasty at adjacent levels unless specifically indicated, as this creates biomechanical inconsistency 1.
- If multilevel surgery is required, use a uniform approach (all fusion or all arthroplasty at contiguous levels) 1, 2.
Approved Alternative: CPT Codes for ACDF
Recommended CPT Codes
- CPT 22551 (Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2) x3 levels 4.
- CPT 22845 (Anterior instrumentation; 2 to 3 vertebral segments) for anterior cervical plating 4.
- CPT 63081 (Vertebral corpectomy, anterior; cervical, single segment) and 63082 (Add-on for each additional segment) as requested 1.