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Date Printed: June 26, 2017: 01:28 AM

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02-20000-45

Original Effective Date: 07/01/15

Reviewed: 03/23/17

Revised: 04/15/17

Subject: Cervical Spine Surgery

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Degenerative cervical spine disorders, while often benign and episodic in nature, can become debilitating, resulting in axial pain and neurological damage to the spinal cord. Compression on the nerve root and / or spinal cord may be caused by (1) a herniated disc with or without extrusion of disc fragments and/or (2) degenerative cervical spondylosis.

Spine surgery is a complex area of medicine. Operative treatment is indicated only when the natural history of an operatively treatable problem is better than the natural history of the problem without operative treatment. Choice of surgical approach is based on anatomy, the candidate’s pathology, and the surgeon's experience and preference. All operative interventions must be based on a positive correlation with clinical findings, the natural history of the disease, the clinical course, and diagnostic tests or imaging results.

Anterior surgical approaches

Anterior surgical approaches to cervical spine decompression emerged in the 1950s in response to technical limitations experienced with posterior approaches, including restricted access to and exposure of midline bony spurs and disc fragments. Anterior approaches include anterior cervical discectomy and fusion. Discectomy is removal of all or part of a herniated or ruptured disc or spondolytic bony spur to alleviate pressure on the nerve roots or on the spinal cord in individuals with symptomatic radiculopathy. Discectomy is most often combined with fusion to stabilize the spine.

Posterior surgical approaches

Posterior surgical approaches include laminectomy, laminoplasty, and laminoforaminotomy (also known as posterior discectomy). Laminectomy is the removal of the bone between the spinal process and facet pedicle junction to expose the neural elements of the spine. This allows for the inspection of the spinal canal, identification and removal of pathological tissue, and decompression of the cord and roots. Laminoplasty is the opening of the lamina to enlarge the spinal canal. There are several laminoplasty techniques; all aim to alleviate cord compression by reconstructing the spinal canal. Laminoplasty is commonly performed to decompress the spinal cord in those with degenerative spinal stenosis.

Laminoforaminotomy (also known as posterior discectomy) is the creation of a small window in the lamina to facilitate removal of arthritic bone spurs and herniated disc material pressing on the nerve root as it exits through the foramen. The opening of the foramen is widened so that the nerve exits without being compressed.

Cervical Artificial Disc

Artificial total disc replacement refers to the insertion of a prosthetic device into the intervertebral space. The goal is to maintain physiologic motion in adults with degenerative disc disease (DDD). An artificial disc is intended to preserve range of motion (ROM) and reduce pain. These prostheses replace the degenerated disc and have been proposed as a means of improving flexibility, maintaining spinal curvature and providing an equalized weight-bearing surface, while reducing or possibly eliminating pain. Several prosthetic devices are currently available for artificial total disc replacement.

POSITION STATEMENT:

Anterior Cervical Decompression with Fusion (ACDF) (Single Level or Multiple Levels)

Anterior cervical discectomy and fusion at a single or multiple levels, with either a bone bank allograft or autograft with or without plating, meets the definition of medical necessity when:

• There are positive clinical findings of myelopathy with evidence of progressive neurologic deficits consistent with worsening spinal cord compression (immediate surgical evaluation is indicated, no conservative treatment required); symptoms may include:

• Upper extremity weakness

• Unsteady gait related to myelopathy, balance or generalized lower extremity weakness

• Disturbance with coordination

• Hyperreflexia

• Hoffmann sign

• Positive Babinski sign and/or clonus

OR

• There is progressive neurological deficit (motor deficit, bowel or bladder dysfunction) with evidence of spinal cord or nerve root compression on Magnetic Resonance Imaging (MRI) or Computed Tomography (CT) imaging (immediate surgical evaluation is indicated, no conservative treatment required)

OR

• When ALL of the following are met:

• Cervical radiculopathy or myelopathy from ruptured disc, spondylosis, spinal instability, or deformity, AND

• Persistent or recurrent symptoms/pain with functional limitations that are unresponsive to at least 6 weeks of appropriate conservative treatment, defined as documented failure of at least 6 consecutive weeks of ANY TWO (2) of the following physician-directed treatments:

Analgesics, steroids, and/or NSAIDs

Structured program of physical therapy

Structured home exercise program prescribed by a physical therapist, chiropractic provider, or physician

Epidural steroid injections and/or facet injections/selective nerve root block, AND

• Imaging studies (MRI or CT with or without myelography) confirm the presence of spinal cord or spinal nerve root compression (disc herniation or foraminal stenosis) at the level(s) corresponding with the clinical findings

OR

• As first-line treatment without conservative treatment in the following clinical scenarios:

• Significant spinal cord or nerve root compression due to tumor, infection or trauma

• Fracture or instability on radiographic films measuring:

• Sagittal plan angulation of greater than 11 degrees at a single interspace, OR

• Greater than 3.5mm anterior subluxation in association with radicular / cord dysfunction, OR

• Subluxation at the (C1) level of the atlantodental interval of more than 3 mm in an adult and 5 mm in a child

NOTE: ACDF at a single level or at multiple levels is not recommended for the following:

• In asymptomatic or mildly symptomatic cases of cervical spinal stenosis

• In cases of neck pain alone, without neurological deficits, and no evidence of significant spinal nerve root or cord compression on MRI or CT

Posterior Cervical Decompression with Fusion (Single Level or Multiple Levels)

Posterior cervical decompression with fusion at a single level or multiple levels meets the definition of medical necessity for cervical spine stenosis and/or cervical spondylotic myelopathy (CSM) when:

• There are positive clinical findings of myelopathy with evidence of progressive neurologic deficits consistent with worsening spinal cord compression (immediate surgical evaluation is indicated, no conservative treatment required); symptoms may include:

• Upper extremity weakness

• Unsteady gait related to myelopathy/balance or generalized lower extremity weakness

• Disturbance with coordination

• Hyperreflexia

• Hoffmann sign

• Positive Babinski sign and/or clonus

OR

• There is progressive neurological deficit (motor deficit, bowel or bladder dysfunction) with evidence of spinal cord or nerve root compression on Magnetic Resonance Imaging (MRI) or Computed Tomography (CT) imaging (immediate surgical evaluation is indicated, no conservative treatment required)

OR

• When ALL of the following are met:

• Cervical radiculopathy or myelopathy from ruptured disc, spondylosis, spinal instability, or deformity, AND

• Persistent or recurrent symptoms/pain with functional limitations that are unresponsive to at least 6 weeks of conservative treatment, defined as documented failure of at least 6 consecutive weeks of ANY TWO (2) of the following physician-directed treatments:

Analgesics, steroids, and/or NSAIDs

Structured program of physical therapy

Structured home exercise program prescribed by a physical therapist, chiropractic provider, or physician

Epidural steroid injections and/or facet injections/selective nerve root block, AND

• Imaging studies (MRI or CT with or without myelography) confirm the presence of spinal cord or spinal nerve root compression (disc herniation or foraminal stenosis) at the level(s) corresponding with the clinical findings, AND

• Symptomatic cervical disease at a single or multiple levels as evidenced by:

• Cervical spinal stenosis due to cervical spondylotic myelopathy (CSM), OR

• Cervical spinal stenosis due to ossification of the posterior longitudinal ligament (OPLL), OR

• Spinal cord or nerve root compression due to herniated disc at a single level or multiple levels

OR

• As first-line treatment without conservative treatment in the following clinical scenarios:

• Significant spinal cord or nerve root compression due to tumor, infection or trauma

• Fracture or instability on radiographic films measuring:

• Sagittal plan angulation of greater than 11 degrees at a single interspace, OR

• Greater than 3.5mm anterior subluxation in association with radicular / cord dysfunction, OR

• Subluxation at the (C1) level of the atlantodental interval of more than 3 mm in an adult and 5 mm in a child

NOTE: Posterior cervical decompression with fusion at a single level or at multiple levels is not recommended for the following:

• In asymptomatic or mildly symptomatic cases of cervical spinal stenosis

• In cases of neck pain alone, without neurological deficits, and no evidence of significant spinal nerve root or cord compression on MRI or CT

• In individuals with kyphosis or at risk for development of postoperative kyphosis

Cervical Fusion for Treatment of Axial Neck Pain

Cervical fusion for the treatment of axial neck pain meets the definition of medical necessity when:

• There is non-radicular cervical pain, AND

• Improvement of symptoms has failed or plateaued, AND

• Residual symptoms of pain and functional disability are unacceptable after 6 to 12 consecutive months of appropriate, active treatment, or after longer duration of non-operative treatment for debilitated individuals with complex problems, AND

• All pain generators are adequately defined and treated, AND

• All physical medicine and manual therapy interventions are completed, AND

• X-ray, MRI, or CT demonstrates disc pathology or spinal instability, AND

• Spine pathology is limited to one or two levels unless other complicating factors are involved, AND

• Psychosocial evaluation for confounding issues, if any, have been addressed

NOTE: The effectiveness of three-level or greater cervical fusion for non-radicular pain has not been established.

Posterior Cervical Decompression

Posterior cervical nerve root decompression meets the definition of medical necessity to treat radiculopathy, disc herniation or foraminal stenosis when:

• There are positive clinical findings of myelopathy with evidence of progressive neurologic deficits consistent with worsening spinal cord compression (immediate surgical evaluation is indicated, no conservative treatment required); symptoms may include:

• Upper extremity weakness

• Unsteady gait related to myelopathy/balance or generalized lower extremity weakness

• Disturbance with coordination

• Hyperreflexia

• Hoffmann sign

• Positive Babinski sign and/or clonus

OR

• There is progressive neurological deficit (motor deficit, bowel or bladder dysfunction) with evidence of spinal cord or nerve root compression on Magnetic Resonance Imaging (MRI) or Computed Tomography (CT) imaging (immediate surgical evaluation is indicated, no conservative treatment required)

OR

• When ALL of the following are met:

• Cervical radiculopathy from ruptured disc, spondylosis, or deformity, AND

• Persistent or recurrent symptoms/pain with functional limitations that are unresponsive to at least 6 weeks of appropriate conservative treatment, defined as documented failure of at least 6 consecutive weeks of ANY TWO (2) of the following physician-directed treatments:

Analgesics, steroids, and/or NSAIDs

Structured program of physical therapy

Structured home exercise program prescribed by a physical therapist, chiropractic provider, or physician

Epidural steroid injections and/or facet injections/selective nerve root block, AND

• Imaging studies (MRI or CT with or without myelography) confirm the presence of spinal cord or spinal nerve root compression at the level(s) corresponding with the clinical findings

OR

• As first-line treatment without conservative treatment for significant spinal cord or nerve root compression due to tumor, infection or trauma

NOTE: Posterior cervical decompression is not recommended for the following:

• In asymptomatic or mildly symptomatic cases

• In cases of pain alone, without neurological deficits, and abnormal imaging findings

Cervical Artificial Disc

Artificial cervical disc replacement at one or two levels meets the definition of medical necessity when all of the following are met:

• The artificial disc is FDA-approved, AND

• Skeletally mature, AND

• Intractable radiculopathy caused by one or two level disease (either herniated disc or spondolytic osteophyte) located at C3-C7, AND

Persistent or recurrent symptoms of pain with functional limitations that are unresponsive to at least 6 weeks of appropriate conservative treatment, defined as documented failure of at least 6 consecutive weeks of ANY TWO (2) of the following physician-directed treatments:

Analgesics, steroids, and/or NSAIDs

Structured program of physical therapy

Structured home exercise program prescribed by a physical therapist, chiropractic provider, or physician

Epidural steroid injections and/or facet injections/selective nerve root block, AND

• Imaging studies confirm the presence of compression at the level(s) corresponding with the clinical findings (MRI or CT), AND

• No prior neck surgery

Artificial cervical disc replacement at more than two levels is considered experimental or investigational. There is a lack of clinical data to permit conclusions on net health outcomes.

NOTE: Artificial cervical disc replacement is NOT indicated when any of the following clinical scenarios exist:

• Symptomatic multiple level disease affecting three or more levels

• Adjacent level disease: degenerative disease adjacent to a previous cervical fusion

• Infection (at site of implantation or systemic)

• Osteoporosis or osteopenia

• Instability:

• Translation greater than 3mm difference between lateral flexion-extension views at the symptomatic levels;

• 11 degrees of angular difference between lateral flexion-extension views at the symptomatic levels

• Sensitivity or allergy to implant materials

• Severe spondylosis defined as:

• >50% disc height loss compared to minimally or non-degenerated levels, OR

• Bridging osteophytes, OR

• Absence of motion on lateral flexion-extension views at the symptomatic site

• Severe facet arthropathy

• Ankylosing spondylitis

• Rheumatoid arthritis

• Previous fracture with anatomical deformity

• Ossification of the posterior longitudinal ligament (OPLL)

• Active cervical spine malignancy

Cervical Fusion without Decompression

Cervical fusion without decompression is reviewed on a case-by-case basis. Atraumatic instability due to Down Syndrome-related spinal deformity, rheumatoid arthritis, or basilar invagination is uncommon, but may require cervical fusion.

Cervical Anterior Decompression without Fusion

Anterior decompression without fusion is reviewed on a case-by-case basis.

Additional information

Conservative treatment

Musculoskeletal conservative treatment should include a multimodality approach consisting of a combination of active and inactive components. Inactive components are modalities such as rest, ice, heat, modified activities, medical devices, acupuncture and/or stimulators, medications, and injections. Active components may consist of physical therapy, a physician supervised home exercise program, and/or chiropractic care.

Home Exercise Program

A home exercise program must include both of the following elements:

• Member is provided an exercise prescription/plan

• Follow up with member is conducted regarding completion of HEP (after suitable 4-6 week period), or inability to complete HEP due to a physical reason (e.g., increased pain, inability to physically perform exercises; member inconvenience or noncompliance without explanation does not constitute an inability to complete HEP)

Contraindications to spine surgery:

• Medical contraindications (e.g., severe osteoporosis; infection of soft tissue adjacent to the spine, whether or not it has spread to the spine; severe cardiopulmonary disease; anemia; malnutrition; systemic infection)

• Non-physiologic modifiers of pain presentation or non-operative conditions mimicking radiculopathy or instability (e.g., peripheral neuropathy, piriformis syndrome, myofascial pain, sympathetically mediated pain syndromes, sacroiliac dysfunction, psychological conditions)

• Active tobacco use prior to fusion surgery (stopping smoking for at least six weeks prior to surgery and during the period of fusion healing is generally recommended)

• Morbid obesity (significant risk and concern for improper post-operative healing, post-operative complications related to morbid obesity, and/or an inability to participate in post-operative rehabilitation)

BILLING/CODING INFORMATION:

CPT Coding

0095T

Removal of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for primary procedure)

0098T

Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for primary procedure)

0375T

Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), cervical, three or more levels (investigational)

22548

Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2 (atlas-axis), with or without excision of odontoid process

22551

Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2

22552

Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace (List separately in addition to code for separate procedure)

22554

Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2

22585

Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (List separately in addition to code for primary procedure)

22590

Arthrodesis, posterior technique, craniocervical (occiput-C2)

22595

Arthrodesis, posterior technique, atlas-axis (C1-C2)

22600

Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment

22614

Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List separately in addition to code for primary procedure)

22856

Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); single interspace, cervical

22858

Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); second level, cervical (List separately in addition to code for primary procedure)

22861

Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical

22864

Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical

63001

Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; cervical

63015

Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; cervical

63020

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, cervical

63035

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additional interspace, cervical or lumbar (List separately in addition to code for primary procedure)

63040

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; cervical

63043

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional cervical interspace (List separately in addition to code for primary procedure)

63045

Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; cervical

63048

Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure)

63050

Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments;

63051

Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments; with reconstruction of the posterior bony elements (including the application of bridging bone graft and non-segmental fixation devices [eg, wire, suture, mini-plates], when performed)

63075

Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace

63076

Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, each additional interspace (List separately in addition to code for primary procedure)

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products: The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Noncovered Services (L33777), located at fcso.com.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

02-20000-48, Lumbar Spine Surgery

OTHER:

None applicable.

REFERENCES:

  1. Ament JD, Yang Z, Nunley P, Stone MB, Lee D, Kim KD. Cost Utility Analysis of the Cervical Artificial Disc vs Fusion for the Treatment of 2-Level Symptomatic Degenerative Disc Disease: 5-Year Follow-up. Neurosurgery. 2016 Feb 5.
  2. American Academy of Orthopaedic Surgeons (AAOS). Cervical Spondylotic Myelopathy: Surgical Treatment Options. November 2009. Accessed at http://orthoinfo.aaos.org/.
  3. Anderson, P.A., Matz, P.G., Groff, M.W., Heary, R.F., Holly, L.T., Kaiser, M.G, Resnick, D.K., Joint Section on Disorders of the Spine and Peripheral Nerves [trunc]. (2009). Laminectomy and fusion for the treatment of cervical degenerative myelopathy. Neurosurg Spine, 11, 150-6.
  4. Blue Cross Blue Shield Association Medical Policy Reference Manual. 7.01.108, Artificial Intervertebral Disc: Cervical Spine. September 2016.
  5. Blue Cross Blue Shield Association Medical Policy Reference Manual. 7.01.145, Laminectomy. January 2015.
  6. Blue Cross Blue Shield Association Medical Policy Reference Manual. 7.01.146, Discectomy. December 2014.
  7. Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Artificial intervertebral disc arthroplasty for treatment of degenerative disk disease of the cervical spine. TEC Assessments 2013.
  8. Botelho RV, Dos Santos Buscariolli Y, de Barros Vasconcelos Fernandes Serra MV, Bellini MN, Bernardo WM. The choice of the best surgery after single level anterior cervical spine discectomy: a systematic review. Open Orthop J. 2012;6:121-128.
  9. Cheng L, Nie L, Zhang L, Hou Y. Fusion versus Bryan Cervical Disc in two-level cervical disc disease: a prospective, randomised study. Int Orthop. 2009 Oct;33(5):1347-51.
  10. Cincu R, Lorente Fde A, Gomez J, Eiras J, Agrawal A. Long term preservation of motion with artificial cervical disc implants: A comparison between cervical disc replacement and rigid fusion with cage. Asian J Neurosurg. 2014 Oct-Dec;9(4):213-7.
  11. ClinicalTrials.gov. NCT00637156: Study of the Safety and Effectiveness of the Artificial Cervical Disc - Low Profile Device at Two Adjacent Levels. Medtronic Spinal and Biologics. October 2015.
  12. Coric D. ISASS Policy Statement - Cervical Artificial Disc. Int J Spine Surg. 2014 Dec 1;8:1-11.
  13. Davis RJ, et al. Two-level total disc replacement with Mobi-C cervical artificial disc versus anterior discectomy and fusion: a prospective, randomized, controlled multicenter clinical trial with 4-year follow-up results. J Neurosurg Spine. 2015 Jan;22(1):15-25.
  14. First Coast Service Options, Inc. (FCSO). LCD for Noncovered Services (L29288), 04/15. (Retired 09/30/15)
  15. First Coast Service Options, Inc. (FCSO). LCD for Noncovered Services (L33777), 10/15.
  16. Gebremariam L, Koes BW, Peul WC, Huisstede BM. Evaluation of treatment effectiveness for the herniated cervical disc: a systematic review. Spine (Phila Pa 1976). 2012;37(2):E109-E118.
  17. Hisey MS, Bae HW, Davis R, Gaede S, Hoffman G, Kim K, Nunley PD, Peterson D, Rashbaum R, Stokes J. Multi-center, Prospective, Randomized, Controlled Investigational Device Exemption Clinical Trial Comparing Mobi-C Cervical Artificial Disc to Anterior Discectomy and Fusion in the Treatment of Symptomatic Degenerative Disc Disease in the Cervical Spine. Int J Spine Surg. 2014 Dec 1;8:1-28.
  18. Holly LT, Matz PG, Anderson PA, et al.; Joint Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons and Congress of Neurological Surgeons. Clinical prognostic indicators of surgical outcome in cervical spondylotic myelopathy. J Neurosurg Spine. 2009;11(2):112-118.
  19. Jackson RA, et al. Subsequent surgery rates after cervical total disc replacement using a Mobi-C Cervical Disc Prosthesis versus anterior cervical discectomy and fusion: a prospective randomized clinical trial with 5-year follow-up. J Neurosurg Spine. 2016 May;24(5):734-45.
  20. Liao Z, Fogel GR, Pu T, Gu H, Liu W. Biomechanics of Hybrid Anterior Cervical Fusion and Artificial Disc Replacement in 3-Level Constructs: An In Vitro Investigation. Med Sci Monit. 2015 Nov 3;21:3348-55.
  21. National Imaging Associates Clinical Guidelines (Magellan Health). 2016 Musculoskeletal Spine Surgery Guidelines: Cervical Artificial Disc.
  22. National Imaging Associates, Inc. Cervical Spine Surgery Clinical Guideline, 2016.
  23. National Imaging Associates, Inc. Cervical Spine Surgery Clinical Guideline, 2017.
  24. National Institute for Clinical Excellence (NICE). Interventional procedure guidance 341: Prosthetic intervertebral disc replacement in the cervical spine. London, UK: NICE; May 2010.
  25. North American Spine Society. Defining appropriate coverage positions: Cervical Artificial Disc Replacement. © American Spine Society. July 2015.
  26. Radkliff K, et al. Replacement compared with anterior discectomy and fusion for treatment of 2-level symptomatic degenerative disc disease: a prospective, randomized, controlled, multicenter investigational device exemption clinical trial. J Neurosurg Spine March 25, 2016.
  27. Zhu, B., Xu, Y., Liu, X., Liu, Z., & Dang, G. (2013). Anterior approach versus posterior approach for the treatment of multilevel cervical spondylotic myelopathy: a systemic review and meta-analysis. Eur Spine J., 22, 1583-93.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the Florida Blue Medical Policy & Coverage Committee on 03/23/17.

GUIDELINE UPDATE INFORMATION:

07/01/15

New Medical Coverage Guideline.

07/15/16

Unscheduled review. Maintained Position Statement section. Revised Program Exceptions section. Updated references.

12/15/16

Revision: added coverage criteria for artificial cervical disc replacement at two levels. Updated references.

04/15/17

Revision: clarified requirements for conservative treatment; added “and/or clonus” at each reference to “positive Babinski sign” in the guideline; deleted smoking cessation requirement for cervical artificial disc replacement. Updated references.

Date Printed: June 26, 2017: 01:28 AM