CMM-610: Lumbar Total Disc Arthroplasty

Initial primary lumbar total disc arthroplasty is medically necessary only for single‑level L4‑5 or L5‑S1 degenerative disc disease in patients aged 18–60 who meet all criteria: FDA‑approved device used per labeling; ≥1 year of chronic discogenic axial back pain with VAS/NRS ≥7 and documented functional impairment; absence of unmanaged significant mental/behavioral disorders; failure of structured, physician‑supervised multimodal nonoperative care for ≥6 months (including prescription analgesics/steroids/NSAIDs and a provider‑directed exercise program); recent (≤6 months) imaging confirming moderate‑to‑severe single‑level degeneration and absence of exclusionary findings; adequate endplate dimensions and bone density (DEXA T‑score ≥ −1.0); and complete supporting documentation and prior authorization where required. Not covered are revisions, multi‑level or simultaneous implants, hybrid/fusion procedures, non‑FDA devices or indications, osteopenia/osteoporosis (T < −1.0), spinal stenosis, spondylolisthesis >3 mm, facet ankylosis/severe facet degeneration, infection, tumor, significant deformity (e.g., scoliosis >11°), autoimmune arthropathies, inadequate disc height or canal dimensions, isolated radicular syndromes, and other contraindications listed in the policy.