Artificial disc replacement (ADR)*

* Artificial Disc Replacement is a synonym of Total Disc Arthroplasty (TDA)

Coverage Decision: Covered with conditions

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

For Lumbar ADR (ADR is allowed for one level only):
  • Patients must first complete a structured, intensive, multi-disciplinary program for management of pain;
  • Patients must be 60 years or under at the time of surgery;
  • The disc must be approved by the FDA;
  • 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;
    • FDA general contra-indications for ADR:
      • 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 (ADR is allowed for single level or two adjacent levels when the criteria are met). Refer to the medical treatment guideline Diagnosis and Treatment of Cervical Radiculopathy and Myelopathy for the criteria.

Background Policy Information

The State Health Technology Clinical Committee (HTCC) reviewed the data of single level artificial disc replacement for treatment of uncomplicated degenerative disc disease on October 17, 2008. The committee’s determination, based on a systematic review of the evidence of safety, efficacy and cost-effectiveness, is that single level artificial disc replacement is a covered benefit with conditions.  Complete information on this HTCC determination is available here: http://www.hca.wa.gov/hta/Pages/Forms/HTA_Findings.aspx.  L&I adopted the above coverage decision in March 2009. 

The subcommittee for cervical spinal surgery of the Industrial Insurance Medical Advisory Committee (IIMAC) reviewed the evidence of safety and efficacy for 2-level cervical ADR in September 2014, and IIMAC recommended L&I cover 2-level cervical ADR if patients meet the criteria (please refer to Diagnosis and Treatment of Cervical Radiculopathy and Myelopathy for details).  L&I has adopted the IIMAC’s recommendation. 

Implementation of the Determination

ADR may be used only for care of a condition accepted on the claim. All requests require prior authorization.

For State Fund Claims

Please contact Utilization Review Vendor (Qualis): http://www.lni.wa.gov/ClaimsIns/Providers/AuthRef/UtilReview/default.asp

For Self-Insured Claims

Please contact the self-insured employer (SIE) or their third party administrator (TPA). For a list of SIE/TPAs, go to: http://www.Lni.wa.gov/ClaimsIns/Insurance/SelfInsure/EmpList/Default.asp

Billing Codes
CPT Codes: 22856, 22857, 22858, 22861, 22862, 22864, 22865, 0095T and 0098T

CPT Codes not covered: 0163T, 0164T and 0165T

 


For more information:
Contact information.


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