Medical Necessity Determination for CPT 22853 (Intervertebral Biomechanical Device) x2
The requested intervertebral biomechanical devices (synthetic cervical cages/spacers, CPT 22853 x2) are NOT medically necessary for this patient because she does not meet the specific indications required by clinical policy for synthetic cage use in cervical fusion. 1
Critical Gap in Medical Necessity Criteria
The clinical policy bulletin (CPB 0016) explicitly states that synthetic cervical cages/spacers are medically necessary only for specific indications, none of which are documented in this case 1:
Required Indications (None Met):
- Cervical corpectomy - Removal of half or more of vertebral body (not mere osteophyte removal) - NOT DOCUMENTED 1
- Tumor involvement of one or more vertebrae - NOT PRESENT 1
- Greater than 50% compression fracture - NOT PRESENT 1
- Retropulsed bone fragments - NOT DOCUMENTED 1
- Symptomatic central canal stenosis caused by vertebral body pathology (fracture, tumor, deformity) - NOT DOCUMENTED 1
- Pseudarthrosis with prior fusion - NOT APPLICABLE (no prior fusion) 1
- Adjacent level disease with prior plated fusion - NOT APPLICABLE (no prior fusion) 1
What This Patient Actually Has
The MRI findings demonstrate 2:
- Disc degeneration at C5-6 and C6-7 with posterior spondylotic disc displacements
- Mild cord compression
- Right posterior-foraminal disc-spur complex with right-sided cord compression
- Severe right C7 foraminal stenosis
This represents standard degenerative disc disease with radiculopathy and mild myelopathy - NOT vertebral body pathology requiring corpectomy or cage placement. 2
Appropriate Surgical Approach for This Patient
The planned C5-C7 ACDF (anterior cervical discectomy and fusion) with CPT codes 22551 and 22552 is appropriate and meets medical necessity criteria 1. However, the standard ACDF technique for degenerative disc disease typically uses:
- Structural allograft (CPT 20930 - already certified as medically necessary) 1
- Anterior cervical plate fixation (CPT 22845 - already certified) 1
- NOT synthetic cages/spacers unless specific vertebral body pathology exists 1
Clinical Reasoning
The distinction is critical: 2, 1
- Simple discectomy and fusion (removing disc material and osteophytes) = allograft + plate fixation
- Corpectomy (removing substantial vertebral body) = synthetic cage/spacer may be indicated
This patient requires decompression of neural elements compressed by disc-spur complexes, not removal of vertebral bodies 2. The MRI report specifically describes "posterior spondylotic disc displacements" and "disc-spur complex" - terminology indicating disc pathology, not vertebral body destruction 2.
Common Pitfall to Avoid
Do not conflate "biomechanical device" terminology with medical necessity. 1 While synthetic cages provide biomechanical support, their use is restricted to specific clinical scenarios involving vertebral body pathology or revision surgery 1. Standard degenerative disc disease with radiculopathy - even with cord compression - does not meet these criteria 2, 1.
Recommendation
DENY CPT 22853 x2 as not medically necessary per CPB 0016 criteria 1. The surgeon should proceed with standard ACDF technique using structural allograft (CPT 20930) and anterior plate fixation (CPT 22845), both of which are already certified as medically necessary 1.
If the surgeon believes corpectomy is required based on intraoperative findings, documentation must clearly establish removal of half or more of the vertebral body, not simple anterior decompression 1. Pre-operative imaging does not support this level of vertebral body involvement 2.