Is placement of a titanium cage (22853) and removal of anterior and posterior osteophytes (22110) medically necessary for a patient with cervical radiculopathy to the right upper extremity, who has a broad-based disc protrusion and uncovertebral spurring at C6-C7, and has failed conservative therapy?

Medical Necessity Determination for Titanium Cage (22853) and Osteophyte Removal (22110)

The placement of a titanium cage (22853) is medically necessary for this patient, but the removal of anterior and posterior osteophytes (22110) is NOT medically necessary based on current evidence-based guidelines.

Titanium Cage (22853) - MEDICALLY NECESSARY

Interbody fusion devices (synthetic spine cages/spacers) are medically necessary for cervical fusion when patients meet criteria for anterior cervical discectomy and fusion, which this patient clearly does. 1

Patient Meets All Required Criteria:

• Clinical correlation confirmed: Right-sided neck pain with burning quality, reduced sensation in right thumb and index finger (C6 dermatomal distribution), and weak right hand grip directly correlate with imaging findings at C6-C7 1, 2

• Imaging severity threshold met: MRI demonstrates "moderate-to-marked lateral recess narrowing" at C6-C7, which exceeds the required threshold of "moderate, moderate to severe, or severe stenosis" (not merely mild or mild-to-moderate) 1, 2

• Conservative management documented: Patient has failed multiple medications and steroids over the documented duration of symptoms 1, 2

• Functional impairment present: Severe pain with weakness affecting activities of daily living 1

Cage Provides Critical Structural Function:

• The interbody cage provides immediate structural support and maintains disc height, which is critical for foraminal decompression - this is the primary mechanism by which ACDF relieves radiculopathy from foraminal stenosis 1

• For 2-level ACDF, anterior cervical plating reduces pseudarthrosis risk from 4.8% to 0.7% and improves fusion rates from 72% to 91%, making the cage-plate construct the standard of care 1

• The cage serves as the fusion device that allows bone graft incorporation while maintaining the disc space height needed to decompress the neural foramen 1

Osteophyte Removal (22110) - NOT MEDICALLY NECESSARY

Routine direct uncovertebral joint decompression and osteophyte removal should NOT be undertaken during ACDF, as indirect foraminal decompression through disc space distraction provides equivalent clinical outcomes without the added surgical risks. 3

Evidence Against Routine Osteophyte Removal:

• A comparative study of 109 patients demonstrated that ACDF with direct uncovertebral joint decompression versus ACDF with only indirect decompression through disc space distraction showed NO statistically significant difference in clinical outcomes (p>0.05) 3

• Good to excellent results were obtained in 84.5% of patients with direct osteophyte removal versus 84.2% without direct removal - essentially identical outcomes 3

• Fusion rates were 95.8% with direct decompression versus 100% without direct decompression 3

Risks of Direct Osteophyte Removal:

• Known complications of direct uncovertebral joint decompression include vertebral artery injury, dural tears, nerve root injury, loss of biomechanical stability, and increased operative time 3

• Sacrificing the uncovertebral joint increases operative time and potentially increases complication rates without improving outcomes 3

Exception - When Osteophyte Removal IS Indicated:

• Removal of large anterior cervical osteophytes is only medically necessary when they are causing dysphagia (swallowing difficulty) and this has been confirmed by an ENT specialist or certified speech therapist - this patient has NO documented dysphagia 1

Mechanism of Decompression in ACDF:

The primary therapeutic mechanism in ACDF for foraminal stenosis is indirect decompression through disc space distraction, NOT direct osteophyte removal. 3

• Placement of the interbody cage restores disc height, which opens the neural foramen and relieves nerve root compression 1, 3

• This indirect decompression is sufficient for the "uncovertebral spurring" documented on this patient's MRI 3

• The broad-based disc protrusion is addressed by the discectomy itself (22551/22552), not by osteophyte removal 3

Clinical Algorithm for This Case:

1. C5-C6 and C6-C7 anterior cervical discectomy (22551 + 22552): Medically necessary - removes disc material causing compression 1, 2

2. Titanium cage placement (22853): Medically necessary - restores disc height and provides indirect foraminal decompression 1, 3

3. Anterior plate fixation (22846): Medically necessary for 2-level fusion - reduces pseudarthrosis and maintains lordosis 1

4. Morcelized allograft (20930): Medically necessary - standard bone graft for fusion 1

5. Osteophyte removal (22110): NOT medically necessary - indirect decompression via cage placement provides equivalent outcomes without added risk 3

6. Intraoperative monitoring (95940): Standard of care for cervical spine surgery to monitor neural function 1

Critical Pitfall to Avoid:

Do not confuse the presence of osteophytes on imaging with the need for direct osteophyte removal. The imaging finding of "uncovertebral spurring" describes the pathoanatomy but does not mandate direct surgical removal of those osteophytes. The cage placement itself addresses this pathology through indirect decompression. 3