CMM-610: Lumbar Total Disc Arthroplasty

Single‑level lumbar total disc arthroplasty is covered as medically necessary for carefully selected patients age 18–60 using an FDA‑approved device for isolated moderate‑to‑severe degenerative disc disease at L3‑4, L4‑5, or L5‑S1 after failure of at least six months of structured, physician‑supervised multimodal nonoperative management with concordant symptoms and imaging. It is not medically necessary if criteria are not met (including multilevel disease, revision arthroplasty, planned simultaneous fusion) or if any listed contraindications are present (e.g., osteoporosis T‑score <-1.0, severe facet degeneration/ankylosis, spinal stenosis, spondylolisthesis >3 mm, scoliosis >11°, infection/tumor, disc height <3 mm, unmanaged behavioral health/substance disorders); required documentation includes X‑rays/CT/MRI confirmation, treatment records, absence of contraindications, FDA labeling compliance, and prior authorization per CMM‑600.1.

"Contraindication: There is evidence on imaging studies of ANY of the following: Degenerative or lytic spondylolisthesis >3 mm"