BCBS - Florida outlines definition of medical necessity for Cervical Total Disc Replacement (TDR)

[wardbro2]

This may be common information, but the first time I've seen this. It is very encouraging for me as I am in the appeal process with TriCare.

Follow the link below for the entire text.

http://mcgs.bcbsfl.com/?doc=Artifici...ertebral Discs
This excerpt (Position Statement - below) from this BCBS of FL Medical Coverage Guideline regarding Artificial Intervertebral Discs was revised 10/15/2011, and in the preceding Description identifies "The potential to reduce the risk of adjacent-level ... (DDD) ...(as) the major rationale driving the development and use of artificial discs". It also identifies these specific devices: Prestige ST, ProDisc-C, and the Bryan Cervical Disc.

Following their position statement, BCBS of FL list the CPT codes which, in some cases, still identify some cervical disc replacement procedures as "investigational". However, in the case of codes 22856 , 22861 and 22864, they are no longer designated as "investigational". Exceptions listed include the Federal Employee Program, State Account Org and Medicare Advantage.

This Medical Coverage Guidline was approved by the BCBSF Medical Policy & Coverage Committee on Sep 22, 2011

I hope this is helpful to others.

Tim




POSITION STATEMENT:


Cervical total disc replacement (TDR) at a single level meets the definition of medical necessity when ALL of the following criteria are met:

• Non-discogenic pain sources have been excluded, AND
• Symptoms of cervical radiculopathy and/or myelopathy, with or without axial neck pain, AND
• Cervical degenerative disc disease (DDD) at one level from C3 – C7, AND
• Compressive lesion is documented by MRI, CT or myelography, AND
• Failed non-operative treatment, for at least six (6) weeks, including ALL of the following:

• Medications (e.g., NSAIDS, unless contraindicated), AND
• Activity modification, traction therapy, physical therapy or injection therapy, AND

• 18 to 65 years of age.

Cervical total disc replacement is considered experimental or investigational for all other indications, and specifically for the following:

• Post laminectomy with kyphotic deformity
• Translational instability
• Ankylosing spondylitis, rheumatoid arthritis
• Ossification of the posterior longitudinal ligament or diffuse hyperostosis
• Insulin-requiring diabetes mellitus
• Infection
• Pregnancy
• Metabolic bone diseases (e.g., osteoporosis, avascular necrosis, Paget’s disease, osteochondritis dissecans)
• Cervical disc replacement at more than one level.

Lumbar total disc replacement is considered experimental or investigational, as evidence is insufficient to determine whether artificial lumbar discs are beneficial in the short term. The available scientific evidence remains insufficient to permit conclusions concerning the effect of this technology on net health outcomes.

[mccauleyjw]

It appears that BCBS is changing their policy from "Experimental to Medically Necessary". CareFirst BCBS of the DC Metro area did the same. I posted the below several days ago. This is good for those fighting to get an Cervical ADR.


Medical Policy - 7.01.100 - Cervical Vertebral Disc Replacement