0165T — Revise lumb artif disc addl
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Claims for lumbar artificial disc replacement must follow the billing, coding, and other documentation guidelines that complement LCD L37826; submiters must reference LCD L37826 when preparing claims and prior authorization materials.
- This LCD does not specify required documentation, prior authorization, or specific forms for lumbar artificial disc replacement claims.
- For medical necessity clinical coverage criteria, refer to the InterQual® CP: Procedures, Artificial Disc Replacement, Cervical (and for lumbar: InterQual® Client Defined, CP: Procedures, Artificial Disc Replacement, Lumbar (Custom) UHG).
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the service requested; refer to the protocol titled Medical Records Documentation Used for Reviews.
Key Coverage Criteria
- This article does not define clinical indications; clinical coverage for lumbar artificial disc replacement is determined by the Local Coverage Determination L37826.
- No covered indications: lumbar artificial disc replacement is not covered by Medicare under this LCD and NCD 150.10.
- Cervical artificial total disc replacement with an FDA-approved prosthetic intervertebral disc is proven and medically necessary in certain circumstances for treating one-level or two contiguous levels of cervical degenerative disc disease (C3 to C7) in a Skeletally Mature individual with symptomatic radiculopathy and/or myelopathy.
- Cervical artificial disc replacement with an FDA-approved prosthetic intervertebral disc is proven and medically necessary for treating one level or two contiguous levels of cervical degenerative disc disease in a Skeletally Mature individual with a history of cervical spinal fusion at another level (adjacent or non-adjacent).
- Lumbar artificial total disc replacement with an FDA-approved prosthetic intervertebral disc is proven and medically necessary in certain circumstances for treating single level lumbar degenerative disc disease with symptomatic intractable discogenic low back pain in a Skeletally Mature individual.
5 Active Policies
A56390 — Billing and Coding: Lumbar Artificial Disc Replacement
L37826 — Lumbar Artificial Disc Replacement
UHC-POL-total-artificial-disc-replacement-spine — Total Artificial Disc Replacement for the Spine
UMR-POL-UMR-total-artificial-disc-replacement-spine — Total Artificial Disc Replacement for the Spine
SUREST-POL-SUREST-total-artificial-disc-replacement-spine
Related Codes
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