Coverage decision

Cervical and lumbar Artificial Disc Replacement (ADR) is covered for accepted conditions when the following criteria are met:

For Lumbar ADR:

1. Patients must first complete a structured, intensive, multi-disciplinary program for management of pain;
2. Patients must be 60 years or under at the time of surgery;
3. PAtients must meet FDA approved indication for use of the specific ADR device and not have any contra-indications.

FDA approved indications for lumbar ADR includes:

• Failure of at least six months of conservative treatment;
• Skeletally mature patient;
• Replacement of a single disc for degenerative disc disease at one level confirmed by patient history and imaging;

Lumbar ADR, FDA general contra-indications:

• Active systemic infection or infection localized to site of implantation;
• Allergy or sensitivity to implant materials;
• Certain bone and spine diseases (e.g. osteoporosis, spondylosis).

For Cervical ADR

1. Patients must meet FDA approved indications for use of the specific device and not have any contra-indications.

FDA approved indications for cervical ADR includes:

• Skeletally mature patient;
• Reconstruction of a disc following single level discectomy for intractable symptomatic cervical disc disease (radiculopathy or myelopathy)confirmed by patient findings and imaging.

Cervical ADR, FDA general contra-indications:

• Active systemic infection or infection localized to site of implantation;
• Allergy or sensitivity to implant materials;
• Certain bone and spine diseases (e.g. severe spondylosis or marked cervical instability).

Background Policy Information

On October 17, 2008, the State Health Technology Clinical Committee (HTCC)met at an open public meeting to decide whether state agencies should pay for Artificial Disc Replacement (ADR) for treatment of uncomplicated degenerative disc disease. Based on a review of the best available evidence of safety, efficacy and cost-effectiveness, the committee’s determination is that ADR is covered with certain limitations. The determination was made final by the HTCC on March 20, 2009.

Complete information on this HTCC determination is available at: http://www.hta.hca.wa.gov.

All Requests for Artificial Disc Replacement, Revision and Removal Require Prior Authorization

How to request authorization for Artificial Disc Replacement:

For State Fund Claims

All requests are reviewed by L&I’s utilization review (UR) vendor (Qualis). To request a review for an inpatient hospitalization or an outpatient procedure that requires UR, please contact Qualis Health in any of the following ways:

• Web: Qualis Health’s preferred method for receiving UR requests is via a secure, Internet application called iExchange. For more information or to schedule a training session, please go to the Qualis Health web page at:
  http://www.qualishealth.org/cm/washington-landi/web-based_um_request.cfm
• Phone: 800-541-2894 (toll free) or 206-366-3360
• Fax: 877-665-0383 (toll free) or 206-366-3378

For Crime Victims

To request a review for an inpatient hospitalization or an outpatient procedure that requires UR, please contact the Crime Victims’ Compensation Program’s Claim Manager by:

• Phone: 800-762-3716 (toll free)
• Fax: 360-902-5333

Additional information is available at: www.CrimeVictims.Lni.wa.gov

For Self-Insured Claims

Contact the self-insured employer (SIE) or their third party administrator (TPA) to request authorization. For a list of SIE/TPAs, go to:

http://lni.wa.gov/ClaimsIns/Insurance/SelfInsure/EmpList/FindEmps/Default.asp

Billing Codes (HCPCS and Local Codes)

For more information:
Contact information.

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