Is a cervical artificial discectomy (Cerv Artific Discectomy) medically necessary for a patient with chronic cervicothoracic neck pain and a right paracentral disc herniation at C5-6 with ventral cord contact and moderate cervical stenosis?

Medical Necessity Determination for Cervical Artificial Discectomy (CPT 22856)

This cervical artificial disc replacement is NOT medically necessary at this time due to two critical missing requirements: (1) the specific FDA-approved prosthetic device has not been identified, making it impossible to verify age eligibility criteria, and (2) segmental instability has not been definitively ruled out with flexion-extension radiographs, which is an absolute contraindication to arthroplasty. 1

Critical Missing Requirements

1. FDA-Approved Device Specification

• The insurance policy explicitly requires identification of the specific FDA-approved prosthetic device to determine age eligibility, as different devices have different age restrictions 1
• Without knowing which device is planned (e.g., Mobi-C, Prestige, ProDisc-C), it is impossible to verify whether the patient meets age criteria 1
• Each FDA-approved cervical disc has specific age ranges: some require patients to be ≤60 years, others allow up to 65-70 years 1

2. Segmental Instability Assessment

• Flexion-extension cervical radiographs are absolutely required to definitively rule out segmental instability before proceeding with arthroplasty 1
• The current imaging includes only static AP/lateral radiographs from the date provided and MRI, neither of which can adequately assess dynamic instability 1
• Static MRI cannot evaluate segmental instability, and the presence of instability is an absolute contraindication to artificial disc placement 1
• The policy explicitly states "no radiologic evidence of segmental instability" is required, but this has not been documented with appropriate dynamic imaging 1

Clinical Criteria That ARE Met

Appropriate Diagnosis and Severity

• The patient has documented C5-6 right paracentral and foraminal disc extrusion with moderate-to-severe right foraminal stenosis, which meets the policy requirement for "moderate, moderate to severe or severe" stenosis (not mild) 1
• MRI demonstrates nerve root compression at C5-6 corresponding with clinical C6 radiculopathy (right elbow flexion weakness 3/5, diminished C6 dermatome sensation) 1
• The imaging findings directly correlate with clinical symptoms: right upper extremity pain, C6 dermatomal numbness (thumb/index finger), and C6 myotomal weakness (elbow flexion) 1

Failed Conservative Management

• The patient has completed >6 weeks of physical therapy within the last 3 months 1
• Two epidural steroid injections have been performed without symptom relief 1
• Activity modification and oral anti-inflammatory medications have been trialed 1
• Daily pain remains 9/10 with significant functional limitation 1

Functional Impact

• Activities of daily living are significantly limited, including inability to perform strenuous or overhead activities 1
• The patient reports daily pain 9/10, which represents severe functional impairment 1

Alternative Surgical Option: ACDF

If the missing requirements cannot be satisfied for arthroplasty, anterior cervical discectomy and fusion (ACDF) at C5-6 IS medically necessary and represents the gold standard treatment 2

Evidence Supporting ACDF

• ACDF provides 80-90% success rates for arm pain relief in cervical radiculopathy with documented motor weakness and severe foraminal stenosis 1
• ACDF achieves rapid relief (within 3-4 months) of arm/neck pain, weakness, and sensory loss compared to continued conservative treatment 1
• Motor function recovery occurs in 92.9% of patients, with long-term improvements maintained over 12 months 1
• For single-level disease with severe foraminal stenosis, ACDF with uncinectomy allows complete and direct decompression of the exiting nerve root 3

ACDF vs. Arthroplasty Considerations

• Anterior cervical decompression and fusion remains the gold standard for surgical treatment of cervical disc herniation 2
• While cervical disc arthroplasty has shown encouraging results in selected patients, it has not proved superiority to ACDF 2
• At 24 months, 2-level arthroplasty demonstrated lower reoperation rates (3.1% vs 11.4%) compared to ACDF, but this was in a 2-level study, not single-level 4
• The patient's severe foraminal stenosis may be better addressed with ACDF plus uncinectomy for complete nerve root decompression 3

Required Actions Before Approval

For Arthroplasty (CPT 22856)

1. Obtain flexion-extension cervical spine radiographs to definitively rule out segmental instability at C5-6 1
2. Specify the exact FDA-approved cervical disc prosthetic device planned for implantation 1
3. Verify patient age eligibility for the specified device per FDA labeling 1
4. Confirm absence of osteoporosis if required by the specific device (DEXA BMD T-score > -2.5 for certain devices) 1

For ACDF as Alternative

• ACDF at C5-6 can be approved immediately as all clinical criteria are met: documented radiculopathy with objective motor weakness (3/5 elbow flexion), moderate-to-severe foraminal stenosis on MRI correlating with symptoms, failed 6+ weeks conservative therapy, and significant functional impairment 1
• Consider anterior cervical plating to reduce pseudarthrosis risk and maintain cervical lordosis, though evidence for single-level fusion is Class III 1

Common Pitfalls to Avoid

• Do not proceed with arthroplasty without dynamic imaging: Static radiographs and MRI cannot assess instability, and unrecognized instability will lead to implant failure 1
• Do not assume all cervical disc devices have the same age criteria: FDA labeling varies significantly between devices 1
• Do not delay treatment indefinitely: If arthroplasty requirements cannot be met, ACDF is an excellent alternative with Level I evidence supporting its efficacy 1, 2
• Do not ignore the severe foraminal stenosis: This patient may benefit from uncinectomy during anterior decompression for complete nerve root decompression 3