Mountain State Medical Policy Bulletin
Section: Surgery
Number: S-187
Topic: Artificial Intervertebral Disc Replacement
Effective Date: January 1, 2007
Issued Date: September 10, 2007
Date Last Reviewed: 11/2006

General Policy Guidelines

Indications and Limitations of Coverage

Intervertebral disc replacement or spinal arthroplasty (22857, 22862, 22865, 0090T-0098T, 0163T, 0164T, 0165T), using an artificial disc (e.g., Charité), is considered experimental/investigational as a treatment for degenerative disc disease (722.4, 722.51-722.52, 722.6).  Studies regarding this treatment are inadequate to permit scientific conclusions regarding the long-term safety and efficacy of the replacement disc.  Artificial intervertebral disc replacement is not covered and is not eligible for payment.  A participating, preferred, or network provider can bill the member for this service. 

Description

Degenerative disc disease (DDD) involves deterioration of the intervertebral disc that has been confirmed by patient history and radiographic studies.  DDD can lead to disc dehydration, annular tears, and/or loss of disc height or collapse.  This can result in chronic pain due to resultant abnormal motion of the affected spinal segment, biomechanical instability of the spine, and nerve root compression. 

Spinal fusion is a common surgical approach to degenerative disc disease when conservative treatment (i.e., rest, pain medication, physical therapy) fails.  This process involves joining two or more vertebrae together to produce a more stable spine.  Bone grafting or metal hardware is used to perform a spinal fusion.  Fusion eliminates abnormal motion and instability of the spine by altering the biomechanics of the back.  It also restricts motion, which may cause potential premature disc degeneration at adjacent levels of the spine.

As an alternative, artificial intervertebral discs have been developed for the treatment of degenerative disc disease.  Total disc replacement, or spinal arthroplasty, is intended to restore normal disc height, prevent compression of nerve roots, relieve pain, maintain motion at the affected level of the spine, and maintain the normal biomechanics of the adjacent vertebrae after the damaged disc has been removed. 

The Charité artificial intervertebral disc has received approval from the Food and Drug Administration (FDA) for use as a single lumbar disc replacement specific to the L4-S1 area.

This device uses two metal endplates that are press fit into adjacent vertebrae and a central free component that is held into place by the surrounding soft tissue.  The central component shifts dynamically within the disc space during spinal motion, replicating normal movement.


NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes

2285722862228650090T0092T0093T
0095T0096T0098T0163T0164T0165T

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

This policy may not apply to FEP.  Medical Policy is not an authorization, certification, explanation of benefits, or a contract.  Benefits are determined by the Federal Employee Program.

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

National Blue Cross Blue Shield Association Medical Policy 7.01.87, Artificial Intervertebral Disc, 04/01/05

Complications of Artificial Disc Replacement-A Report of 27 Patients with the SB Charité Disc”, Journal of Spinal Disorders & Techniques, Vol. 16, No. 4, April 2003

Neurological Complications of Lumbar Artificial Disc Replacement and Comparison of Clinical Results with Those Related to Lumbar Arthrodesis in the Literature: Results of a Multicenter, Prospective, Randomized Investigational Device Exemption Study of Charité Intervertebral Disc”, Journal of Neurosurgery: Spine, Vol. 1, September 2004

Long-term Results of One-Level Lumbar Arthroplasty, Spine, Vol. 32, No. 6, March 2007

View Previous Versions

[Version 004 of S-187]
[Version 003 of S-187]
[Version 002 of S-187]
[Version 001 of S-187]

Table Attachment

Text Attachment

Procedure Code Attachment


Glossary




This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.