This version of the policy will become effective 01/14/2019.
The Description Section was updated to include information regarding the ActivL® Artificial Disc.
The following statement was added to the Policy Section:
Subsequent cervical artificial intervertebral disc implantation at an adjacent level is considered medically necessary, and therefore, covered when all of the following are met:
When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
0095T, 0098T, 0164T, 0165T, 22856, 22858, 22861, 22862, 22864, 22865
0163T, 0375T, 22857
M50.020 Cervical disc disorder with myelopathy, mid-cervical region, unspecified level
M50.021 Cervical disc disorder at C4-C5 level with myelopathy
M50.022 Cervical disc disorder at C5-C6 level with myelopathy
M50.023 Cervical disc disorder at C6-C7 level with myelopathy
M50.120 Mid-cervical disc disorder, unspecified
M50.121 Cervical disc disorder at C4-C5 level with radiculopathy
M50.122 Cervical disc disorder at C5-C6 level with radiculopathy
M50.123 Cervical disc disorder at C6-C7 level with radiculopathy
M50.220 Other cervical disc displacement, mid-cervical region, unspecified level
M50.221 Other cervical disc displacement at C4-C5 level
M50.222 Other cervical disc displacement at C5-C6 level
M50.223 Other cervical disc displacement at C6-C7 level
M50.320 Other cervical disc degeneration, mid-cervical region, unspecified level
M50.321 Other cervical disc degeneration at C4-C5 level
M50.322 Other cervical disc degeneration at C5-C6 level
M50.323 Other cervical disc degeneration at C6-C7 level
Policy: 11.00.02f:Treatment of Medical and Surgical Complications
Policy: 12.01.01ar:Experimental/Investigational Services