97169
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Claims and coding for cervical disc replacement must follow the Local Coverage Determination (LCD) L38033 and the billing/coding guidelines in this article.
- Documentation must show the CDR device used is FDA-approved for the treated indication (including 2-level approval if applicable).
- Imaging documentation (CT, myelography, or MRI) demonstrating corresponding nerve root or spinal cord compression must be included in the medical record.
- Medical records must document at least 6 weeks of failed conservative non-operative treatment when applicable, including physician-directed pain management and physical therapy.
Key Coverage Criteria
- The prosthetic cervical disc device is FDA-approved for the indicated use.
- The beneficiary is skeletally mature.
- The beneficiary has intractable cervical radicular pain or cervical myelopathy that has failed at least 6 weeks of conservative non-operative treatment including physician-directed pain management (e.g., pharmacotherapy for neuropathic pain) and physical therapy.
- Alternatively, the beneficiary has severe or rapidly progressive symptoms of nerve root or spinal cord compression requiring hospitalization or immediate surgical intervention.
- There must be clinical evidence of corresponding nerve root or spinal cord compression documented by CT, myelography, or MRI.
- Cervical degenerative disc disease (CDDD) at a single level between C3 and C7.
11 Active Policies
A57021 — Billing and Coding: Cervical Disc Replacement
L38033 — Cervical Disc Replacement
CIGNA-CPG135 — Physical Therapy - (CPG135)
CIGNA-CPG155 — Occupational Therapy - (CPG155)
CIGNA-CPG111 — Patient Assessments: Medical Necessity Decision Assist Guideline for Evaluations and Re-evaluations - (CPG111)
Related Codes
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