General Information
It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted.

Purpose
This guideline outlines the key surgical treatments and indications for common cervical spinal disorders and is based upon the best available evidence. Spine surgery is a complex area of medicine, and this document breaks out the clinical indications by surgical type.
This guideline does not address spinal deformity surgeries or the clinical indications for spinal deformity surgery.

Scope
Spinal surgeries should be performed only by those with extensive and specialized surgical training (neurosurgery, orthopedic surgery). Choice of surgical approach is based on anatomy, pathology, and the surgeon's experience and preference.
Instrumentation, bone formation or grafting materials, including biologics, should be used at the surgeon’s discretion; however, use should be limited to FDA approved indications regarding the specific devices or biologics.

Policy 

INDICATIONS
Anterior Cervical Discectomy with Fusion (ACDF) - Single Level
When one of the two following criteria are met ^{(1,2,3,4,5,6,7,8)}:

• Positive clinical findings of myelopathy with evidence of progressive neurologic deficits consistent with spinal cord compression - immediate surgical evaluation is indicated. Symptoms may include ⁽⁹⁾:
  • Upper extremity weakness
  • Unsteady gait related to myelopathy/balance or generalized lower extremity weakness
  • Disturbance with coordination
  • Hyperreflexia
  • Hoffmann sign
  • Positive Babinski sign and/or clonus
• Progressive neurological deficit (motor deficit, bowel or bladder dysfunction) with evidence of spinal cord or nerve root compression on magnetic resonance imaging (MRI) or computed tomography (CT) imaging - immediate surgical evaluation is indicated

When ALL of the following criteria are met ^(8,9,10):

• Cervical radiculopathy or myelopathy from ruptured disc, spondylosis, spinal instability, or deformity
• Failure of conservative treatment* for a minimum of six (6) weeks within the last six (6) months;

NOTE - Failure of conservative treatment is defined as one of the following:

• • Lack of meaningful improvement after a full course of treatment; OR
  • Progression or worsening of symptoms during treatment; OR
  • Documentation of a medical reason the member is unable to participate in treatment

Closure of medical or therapy offices, patient inconvenience, or noncompliance without explanation does not constitute “inability to complete” treatment.

• Imaging studies confirm the presence of spinal cord or spinal nerve root compression (disc herniation or foraminal stenosis) at the level corresponding with the clinical findings. Imaging studies may include:
  • MRI (preferred study for assessing cervical spine soft tissue)
  • CT with or without myelography— indicated in individuals in whom MRI is contraindicated; preferred for examining bony structures, or in individuals presenting with clinical symptoms or signs inconsistent with MRI findings (e.g., foraminal compression not seen on MRI)

As first-line treatment without conservative care measures in the following clinical cases ^(1,2,6,11):

• As outlined above for myelopathy or progressive neurological deficit scenarios
• Significant spinal cord or nerve root compression due to tumor, infection, or trauma
• Fracture or instability on radiographic films measuring:
  • Sagittal plane angulation of greater than 11 degrees at a single interspace or greater than 3.5mm anterior subluxation in association with radicular/cord dysfunction
  • Subluxation at the (C1) level of the atlantodental interval of more than 3mm in an adult and 5mm in a child

Not recommended ⁽¹⁰⁾:

• In asymptomatic or mildly symptomatic cases of cervical spinal stenosis
• In cases of neck pain alone, without neurological deficits, and no evidence of significant spinal nerve root or cord compression on MRI or CT. See Cervical Fusion for Treatment of Axial Neck Pain Criteria

Anterior Cervical Discectomy with Fusion (ACDF) – Multiple Levels

When one of the two following criteria are met ^{(1,2,3,4,5,6,7,8)}:

• Positive clinical findings of myelopathy with evidence of progressive neurologic deficits consistent with worsening spinal cord compression – immediate surgical evaluation is indicated. Symptoms may include:
  • Upper extremity weakness
  • Unsteady gait related to myelopathy/balance or generalized lower extremity weakness
  • Disturbance with coordination
  • Hyperreflexia
  • Hoffmann sign
  • Positive Babinski sign and/or clonus
• Progressive neurological deficit (motor deficit, bowel or bladder dysfunction) with corresponding evidence of spinal cord or nerve root compression on an MRI or CT scan images – immediate surgical evaluation is indicated

When ALL of the following criteria are met ^(8,10):

• Cervical radiculopathy or myelopathy due to ruptured disc, spondylosis, spinal instability, or deformity
• Failure of conservative treatment* for a minimum of six (6) weeks within the last six (6) months;

NOTE - Failure of conservative treatment is defined as one of the following:

• • Lack of meaningful improvement after a full course of treatment; OR
  • Progression or worsening of symptoms during treatment; OR
  • Documentation of a medical reason the member is unable to participate in treatment

Closure of medical or therapy offices, patient inconvenience, or noncompliance without explanation does not constitute “inability to complete” treatment.

• Imaging studies confirm the presence of spinal cord or spinal nerve root compression (disc herniation or foraminal stenosis) at multiple levels corresponding with the clinical findings. Imaging studies may include any of the following:
  • MRI (preferred study for assessing cervical spine soft tissue)
  • CT with or without myelography - indicated in individuals in whom MRI is contraindicated; preferred for examining bony structures, or in individuals presenting with clinical symptoms or signs inconsistent with MRI findings (e.g., foraminal compression not seen on MRI)

As first-line treatment without conservative care measures in the following clinical cases ^(1,2,6,11):

• As outlined above for myelopathy or progressive neurological deficit scenarios
• Significant spinal cord or nerve root compression due to tumor, infection, or trauma
• Fracture or instability on radiographic films measuring:
  • Sagittal plane angulation of greater than 11 degrees at a single interspace or greater than 3.5mm anterior subluxation in association with radicular/cord dysfunction
  • Subluxation at the (C1) level of the atlantodental interval of more than 3mm in an adult and 5mm in a child

Not recommended ⁽¹⁰⁾:

• In asymptomatic or mildly symptomatic cases of cervical spinal stenosis
• In cases of neck pain alone, without neurological deficits, and no evidence of significant spinal nerve root or cord compression on MRI or CT. See Cervical Fusion for Treatment of Axial Neck Pain Criteria

Cervical Posterior Decompression with Fusion - Single Level

When one of the two following criteria are met ^{(1,2,3,4,5,6,7,8,12)}:

• Positive clinical findings of myelopathy with evidence of progressive neurologic deficits consistent with worsening spinal cord compression - immediate surgical evaluation is indicated. Symptoms may include:
  • Upper extremity weakness
  • Unsteady gait related to myelopathy/balance or generalized lower extremity weakness
  • Disturbance with coordination
  • Hyperreflexia
  • Hoffmann sign
  • Positive Babinski sign and/or clonus
• Progressive neurological deficit (motor deficit, bowel or bladder dysfunction) with corresponding evidence of spinal cord or nerve root compression on an MRI or CT scan images - immediate surgical evaluation is indicated

When ALL of the following criteria are met ^(8,10):

• Cervical radiculopathy or myelopathy from ruptured disc, spondylosis, spinal instability, or deformity
• Failure of conservative treatment* for a minimum of six (6) weeks within the last six (6) months;

NOTE - Failure of conservative treatment is defined as one of the following:

• • Lack of meaningful improvement after a full course of treatment; OR
  • Progression or worsening of symptoms during treatment; OR
  • Documentation of a medical reason the member is unable to participate in treatment

Closure of medical or therapy offices, patient inconvenience, or noncompliance without explanation does not constitute “inability to complete” treatment.

• Imaging studies confirm the presence of spinal cord or spinal nerve root compression (disc herniation or foraminal stenosis) at single level corresponding with the clinical findings. Imaging studies may include:
  • MRI (preferred study for assessing cervical spine soft tissue)
  • CT with or without myelography – indicated in individuals in whom MRI is contraindicated; preferred for examining bony structures, or in individuals presenting with clinical symptoms or signs inconsistent with MRI findings (e.g., foraminal compression not seen on MRI)

As first-line treatment without conservative care measures in the following clinical cases ^{(1,2,6,11,12)}:

• As outlined above for myelopathy or progressive neurological deficit scenarios
• Significant spinal cord or nerve root compression due to tumor, infection, or trauma
• Fracture or instability on radiographic films measuring:
  • Sagittal plane angulation of greater than 11 degrees at a single interspace or greater than 3.5mm anterior subluxation in association with radicular/cord dysfunction
  • Subluxation at the (C1) level of the atlantodental interval of more than 3mm in an adult and 5mm in a child

Not recommended ⁽¹⁰⁾:

• In asymptomatic or mildly symptomatic cases of cervical spinal stenosis
• In cases of neck pain alone, without neurological deficits, and no evidence of significant spinal nerve root or cord compression on MRI or CT. See Cervical Fusion for Treatment of Axial Neck Pain Criteria

Cervical Posterior Decompression with Fusion – Multiple Levels

When one of the two following criteria are met ^{(1,2,3,4,5,6,7,8,12)}:

• Positive clinical findings of myelopathy with evidence of progressive neurologic deficits consistent with worsening spinal cord compression – immediate surgical evaluation is indicated. Symptoms may include:
  • Upper extremity weakness
  • Unsteady gait related to myelopathy/balance or generalized lower extremity weakness
  • Disturbance with coordination
  • Hyperreflexia
  • Hoffmann sign
  • Positive Babinski sign and/or clonus
• Progressive neurological deficit (motor deficit, bowel or bladder dysfunction) with corresponding evidence of spinal cord or nerve root compression on an MRI or CT scan images – immediate surgical evaluation is indicated

When ALL of the following criteria are met ^(8,10):

• Cervical radiculopathy or myelopathy from ruptured disc, spondylosis, spinal instability, or deformity
• Failure of conservative treatment* for a minimum of six (6) weeks within the last six (6) months;

NOTE - Failure of conservative treatment is defined as one of the following:

• • Lack of meaningful improvement after a full course of treatment; OR
  • Progression or worsening of symptoms during treatment; OR
  • Documentation of a medical reason the member is unable to participate in treatment

Closure of medical or therapy offices, patient inconvenience, or noncompliance without explanation does not constitute “inability to complete” treatment.

• Imaging studies indicate significant spinal cord or spinal nerve root compression at multiple levels corresponding with the clinical findings. Imaging studies may include:
  • MRI (preferred study for assessing cervical spine soft tissue)
  • CT with or without myelography - indicated in individuals in whom MRI is contraindicated; preferred for examining bony structures, or in individuals presenting with clinical symptoms or signs inconsistent with MRI findings (e.g., foraminal compression not seen on MRI)

As first-line treatment without conservative care measures in the following clinical cases ^{(1,2,6,11,12)}:

• As outlined above for myelopathy or progressive neurological deficit scenarios
• Significant spinal cord or nerve root compression due to tumor, infection, or trauma
• Fracture or instability on radiographic films measuring:
  • Sagittal plane angulation of greater than 11 degrees at a single interspace or greater than 3.5mm anterior subluxation in association with radicular/cord dysfunction
  • Subluxation at the (C1) level of the atlantodental interval of more than 3mm in an adult and 5mm in a child

Not recommended ⁽¹⁰⁾:

• In asymptomatic or mildly symptomatic cases of cervical spinal stenosis
• In cases of neck pain alone, without neurological deficits, and no evidence of significant spinal nerve root or cord compression on MRI or CT. See Cervical Fusion for Treatment of Axial Neck Pain Criteria

Cervical Fusion for Treatment of Axial Neck Pain
Fusion In Individuals with Non-Radicular Cervical Pain

ALL of the following criteria must be met ^(13,14)

• Improvement of the symptoms has failed or plateaued, and the residual symptoms of pain and functional disability are unacceptable at the end of 6 to 12 consecutive months of appropriate, active treatment, or at the end of longer duration of non-operative programs for those debilitated with complex problems

[NOTE: Mere passage of time with poorly guided treatment is not considered an active treatment program]

• All pain generators are adequately defined and treated
• All physical medicine and manual therapy interventions are completed
• X-ray, MRI, or CT demonstrating disc pathology or spinal instability
• Spine pathology limited to one or two levels unless other complicating factors are involved
• Psychosocial evaluation for confounding issues addressed

NOTE: The effectiveness of three-level or greater cervical fusion for non-radicular pain has not been established.

Cervical Posterior Decompression

The following criteria must be met* ^{(1,2,4,5,6,7,8,15)}:

• Positive clinical findings of myelopathy with evidence of progressive neurologic deficits consistent with worsening spinal cord compression - immediate surgical evaluation is indicated. Symptoms may include:
  • Upper extremity weakness
  • Unsteady gait related to myelopathy/balance or generalized lower extremity weakness
  • Disturbance with coordination
  • Hyperreflexia
  • Hoffmann sign
  • Positive Babinski sign and/or clonus
• Progressive neurological deficit (motor deficit, bowel or bladder dysfunction) with corresponding evidence of spinal cord or nerve root compression on an MRI or CT scan images - immediate surgical evaluation is indicated

When ALL of the following criteria are met ⁽⁸⁾:

• Cervical radiculopathy from ruptured disc, spondylosis, or deformity
• Failure of conservative treatment* for a minimum of six (6) weeks within the last six (6) months;

NOTE - Failure of conservative treatment is defined as one of the following:

• • Lack of meaningful improvement after a full course of treatment; OR
  • Progression or worsening of symptoms during treatment; OR
  • Documentation of a medical reason the member is unable to participate in treatment

Closure of medical or therapy offices, patient inconvenience, or noncompliance without explanation does not constitute “inability to complete” treatment.

• Imaging studies confirm the presence of spinal cord or spinal nerve root compression at the level(s) corresponding with the clinical findings. Imaging studies may include any of the following:
  • MRI (preferred study for assessing cervical spine soft tissue)
  • CT with or without myelography— indicated in individuals in whom MRI is contraindicated; preferred for examining bony structures, or in individuals presenting with clinical symptoms or signs inconsistent with MRI findings (e.g., foraminal compression not seen on MRI)

Cervical decompression performed as first-line treatment without conservative care in the following clinical cases ^(1,2,6,15):

• As outlined above for myelopathy or progressive neurological deficit scenarios
• Spinal cord or nerve root compression due to tumor, infection, or trauma

Not Recommended ⁽¹⁰⁾:

• In asymptomatic or mildly symptomatic cases
• In cases of neck pain alone, without neurological deficits and abnormal imaging findings. See Cervical Fusion for Treatment of Axial Neck Pain Criteria
• In individuals with kyphosis or at risk for development of postoperative kyphosis

Cervical Artificial Disc Replacement (Single or Two Level) ^(8,16,17)

When all of the following criteria are met:

• Skeletally mature individual
• Intractable radiculopathy caused by one-or-two-level disease (either herniated disc or spondolytic osteophyte) located at C3-C7
• Failure of conservative treatment* for a minimum of six (6) weeks within the last six (6) months;

NOTE - Failure of conservative treatment is defined as one of the following:

• • Lack of meaningful improvement after a full course of treatment; OR
  • Progression or worsening of symptoms during treatment; OR
  • Documentation of a medical reason the member is unable to participate in treatment

Closure of medical or therapy offices, patient inconvenience, or noncompliance without explanation does not constitute “inability to complete” treatment.

• Imaging studies confirm the presence of compression at the level(s) corresponding with the clinical findings (MRI or CT)
• Use of an FDA-approved prosthetic intervertebral discs

Contraindications

• Symptomatic multiple level disease affecting 3 or more levels
• Infection (at site of implantation or systemic)
• Osteoporosis or osteopenia
• Instability
  • Translation greater than 3mm difference between lateral flexion-extension views at the symptomatic levels
  • 11 degrees of angular difference between lateral flexion-extension views at the symptomatic levels
• Sensitivity or allergy to implant materials
• Severe spondylosis defined as:
  • > 50% disc-height loss compared to minimally or non-degenerated levels; OR
  • Bridging osteophytes; OR
  • Absence of motion on lateral flexion-extension views at the symptomatic site
• Severe facet arthropathy
• Ankylosing spondylitis
• Rheumatoid arthritis
• Previous fracture with anatomical deformity
• Ossification of the posterior longitudinal ligament (OPLL)
• Active cervical spine malignancy

Risk Factors and Considerations ^(19,20,21)

• Early intervention may be required in acute incapacitating pain or with progressive neurological deficits
• Individuals may present with pain, numbness, extremity weakness, loss of coordination, gait issues, or bowel and bladder complaints. Non-operative treatment is an important role in the care of individuals with degenerative cervical spine disorders. If these symptoms progress to neurological deficits, from corresponding spinal cord or nerve root compression, surgical intervention may be warranted.
• Obesity is an identified risk factor for surgical site infection. For individuals undergoing posterior cervical decompression with or without fusion for a diagnosis other than myelopathy, BMI should be less than 40. These cases will be reviewed on a case-by-case basis and may be denied given the increased risk of infection.
• If operative intervention is being considered, especially procedures that require a fusion, it is required the person refrain from smoking/nicotine for at least six weeks prior to surgery and during the time of healing.  
• In situations requiring possible need for an operation, a second opinion may be necessary. Psychological evaluation is strongly encouraged before surgery is performed for isolated axial pain to determine if the individual will likely benefit from the treatment.
• It is imperative for the clinician to rule out non-physiologic modifiers of pain presentation, or non-operative conditions mimicking radiculopathy, myelopathy or spinal instability (peripheral compressive neuropathy, chronic soft tissue injuries, and psychological conditions), prior to consideration of elective surgical intervention.

• Active Modalities
  • Physical therapy
  • Physician-supervised home exercise program (HEP)**
  • Chiropractic Care
• Inactive Modalities
  • Medications (e.g., NSAIDs, steroids, analgesics)
  • Injections (e.g., epidural steroid injection, selective nerve root block)
  • Medical devices (e.g., TENS unit, bracing)

**Home Exercise Program (HEP)

The following two elements are required to meet conservative therapy guidelines for HEP:

• Documentation of an exercise prescription/plan provided by a physician, physical therapist, or chiropractor; AND
• Follow-up documentation regarding completion of HEP after the required 6-week timeframe or inability to complete HEP due to a documented medical reason (i.e., increased pain or inability to physically perform exercises)

References 

1. Guo S, Lin T, Wu R, Wang Z, Chen G. The Pre-Operative Duration of Symptoms: The Most Important Predictor of Post-Operative Efficacy in Patients with Degenerative Cervical Myelopathy. Brain Sci. 2022; 12: 1088. 10.3390/brainsci12081088.

2. Kwok S S S, Cheung J P Y. Surgical decision-making for ossification of the posterior longitudinal ligament versus other types of degenerative cervical myelopathy: anterior versus posterior approaches. BMC Musculoskelet Disord. 2020; 21: 823. 10.1186/s12891-020-03830-0.

3. Luyao H, Xiaoxiao Y, Tianxiao F, Yuandong L, Ping W. Management of Cervical Spondylotic Radiculopathy: A Systematic review. Global Spine J. Oct 2022; 12: 1912-1924. 10.1177/21925682221075290.

4. Nunna R, Khalid S, Chiu R, Parola R, Fessler R et al. Anterior vs Posterior Approach in Multilevel Cervical Spondylotic Myelopathy: A Nationwide Propensity-Matched Analysis of Complications, Outcomes, and Narcotic Use. Int J Spine Surg. Feb 2022; 16: 88-94. 10.14444/8198.

5. Park D, Jenne J, Bode K, Throckmorton T, Fischer S. Cervical Spondylotic Myelopathy: Surgical Treatment Options. OrthoInfo. 2022; Accessed: September 4, 2024. https://orthoinfo.aaos.org/en/treatment/cervical-spondylotic-myelopathysurgical-treatment-options/.

6. Tetreault L, Karpova A, Fehlings M. Predictors of outcome in patients with degenerative cervical spondylotic myelopathy undergoing surgical treatment: results of a systematic review. Eur Spine J. Apr 2015; 24 Suppl 2: 236-51. 10.1007/s00586-013-2658-z.

7. Xu Y, Chen F, Wang Y, Zhang J, Hu J. Surgical approaches and outcomes for cervical myelopathy with increased signal intensity on T2-weighted MRI: a meta-analysis. J Orthop Surg Res. 2019; 14: 224. 10.1186/s13018-019-1265-z.

8. North American Spine Society. Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders. 2010; Retrieved 2023, from NASS Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care.

9. Lebl D R, Bono C M. Update on the Diagnosis and Management of Cervical Spondylotic Myelopathy. Journal of the American Academy of Orthopaedic Surgeons. 2015; 23: 648-660. 10.5435/JAAOS-D-14-00250.

10. Nikolaidis I, Fouyas I P, Sandercock P A, Statham P F. Surgery for cervical radiculopathy or myelopathy. Cochrane Database Syst Rev. 2010; 2010: Cd001466. 10.1002/14651858.CD001466.pub3.

11. Spitnale M, Grabowski G. Classification in Brief: Subaxial Cervical Spine Injury Classification and Severity Score System. Clin Orthop Relat Res. Oct 2020; 478: 2390-2398. 10.1097/corr.0000000000001463.

12. Audat Z, Fawareh M, Radydeh A, Obeidat M, Odat M et al. Anterior versus posterior approach to treat cervical spondylotic myelopathy, clinical and radiological results with long period of follow-up. SAGE Open Med. 2018; 6: 2050312118766199. 10.1177/2050312118766199.

13. Riew K, Ecker E, Dettori J. Anterior cervical discectomy and fusion for the management of axial neck pain in the absence of radiculopathy or myelopathy. Evid Based Spine Care J. Dec 2010; 1: 45-50. 10.1055/s-0030-1267067.

14. Harrop J S, Gonzalez G A, Qasba R K, Porto G, Wainwright J V et al. Does axial cervical pain improve with surgical fusion? A meta-analysis. Journal of Neurosurgery: Spine. 2023; 1-10. 10.3171/2023.4.SPINE23185.

15. Revesz D, Charalampidis A, Gerdhem P. Effectiveness of laminectomy with fusion and laminectomy alone in degenerative cervical myelopathy. Eur Spine J. May 2022; 31: 1300-1308. 10.1007/s00586-022-07159-1.

16. Eseonu K, Laurent E, Bishi H, Raja H, Ravi K. A Retrospective Comparative Study of Long-Term Outcomes Following Cervical Total Disc Replacement Versus Anterior Cervical Discectomy and Fusion. Cureus. Dec 2022; 14: e32399. 10.7759/cureus.32399.

17. Nunley P, Frank K, Stone M. Patient Selection in Cervical Disc Arthroplasty. International Journal of Spine Surgery. 2020; 14: S29-S35. 10.14444/7088.

18. Donk R D, Verbeek A L M, Verhagen W I M, Groenewoud H, Hosman A J F. Whats the best surgical treatment for patients with cervical radiculopathy due to single-level degenerative disease? A randomized controlled trial. PLoS One. 2017; 12: e0183603. 10.1371/journal.pone.0183603.

19. Badiee R, Mayer R, Pennicooke B, Chou D, Mummaneni P. Complications following posterior cervical decompression and fusion: a review of incidence, risk factors, and prevention strategies. J Spine Surg. Mar 2020; 6: 323-333. 10.21037/jss.2019.11.01.

20. Jackson K 2, Devine J. The Effects of Smoking and Smoking Cessation on Spine Surgery: A Systematic Review of the Literature. Global Spine J. Nov 2016; 6: 695-701. 10.1055/s-0036-1571285.

21. Rajaee S, Kanim L, Bae H. National trends in revision spinal fusion in the USA: patient characteristics and complications. Bone Joint J. Jun 2014; 96-b: 807-16. 10.1302/0301-620x.96b6.31149.

22. Washington State Health Care Authority. Artificial disc replacement - Re-review [Adopted March 17, 2017]. Washington State Health Care Authority. 2008; Accessed: September 23, 2024. www.hca.wa.gov/assets/program/adr-rr-final-findings-decision-20170317.pdf.

23. Washington State Health Care Authority. Cervical Spinal Fusion for Degenerative Disc Disease [Adopted May 17, 2013]. Washington State Health Care Authority. 2013; Accessed: September 23, 2024. www.hca.wa.gov/assets/program/csf_final_findings_decision_052013%5B1%5D.pdf.

Additional Information
A comprehensive assimilation of factors should lead to a specific diagnosis with positive identification of the pathologic condition(s).

• Early intervention may be required in acute incapacitating pain or in the presence of progressive neurological deficits.
• Operative treatment is indicated when the natural history of surgically treated lesions is better than the natural history for non-operatively treated lesions.
• Patients may present with localized pain or severe pain in combination with numbness, extremity weakness, loss of coordination, gait issues, or bowel and bladder complaints. Nonoperative treatment continues to play an important role in the care of patients with degenerative cervical spine disorders. If these symptoms progress to neurological deficits, from corresponding spinal cord or nerve root compression, than surgical intervention may be warranted.
• All patients being considered for surgical intervention should first undergo a comprehensive neuromusculoskeletal examination to identify those pain generators that may either respond to non-surgical techniques, or may be refractory to surgical intervention.
• In situations requiring the possible need for operation, a second opinion may be necessary. Psychological evaluation is strongly encouraged when surgery is being performed for isolated axial pain to determine if the patient will likely benefit from the treatment.
• It is imperative for the clinician to rule out non-physiologic modifiers of pain presentation, or non-operative conditions mimicking radiculopathy, myelopathy or spinal instability (peripheral compressive neuropathy, chronic soft tissue injuries, and psychological conditions), prior to consideration of elective surgical intervention. Significant depression or psychiatric disorder may be a reason for denial as risk of failure is elevated.

Degenerative cervical spine disorders, while often benign and episodic in nature, can become debilitating, resulting in axial pain and neurological damage to the spinal cord. Compression on the nerve root and / or spinal cord may be caused by (1) a herniated disc with or without extrusion of disc fragments and/or (2) degenerative cervical spondylosis.

Anterior Approaches — Additional Information:

• Anterior surgical approaches to cervical spine decompression emerged in the 1950s in response to technical limitations experienced with posterior approaches, including restricted access to and exposure of midline bony spurs and disc fragments.
• The first reports in the literature describe anterior cervical discectomy combined with a spinal fusion procedure (ACDF). Fusion was added to address concerns about potential for loss of spinal stability and disc space height, leading to late postoperative complications such as kyphosis and radicular pain (Sonntag and Klara, 1996; Dowd and Wirth, 1999; Matz et al., 2009a; Matz et al., 2009b; Denaro and Di Martino, 2011; Botelho et al., 2012; van Middelkoop et al., 2012).
• Anterior cervical fusion (ACF) accounted for approximately 80% of cervical spine procedures performed in the United States between 2002 and 2009, while posterior cervical fusion (PCF) accounted for 8.5% of these procedures (Oglesby et al., 2013).
• Anterior Cervical Discectomy and Fusion (ACDF) – removal of all or part of a herniated or ruptured disc or spondolytic bony spur to alleviate pressure on the nerve roots or on the spinal cord in patients with symptomatic radiculopathy. Discectomy is most often combined with fusion to stabilize the spine.

Posterior Approaches
Laminectomy — Removal of the bone between the spinal process and facet pedicle junction to expose the neural elements of the spine’ this allows for the inspection of the spinal canal, identification and removal of pathological tissue, and decompression of the cord and roots.

Laminoplasty — The opening of the lamina to enlarge the spinal canal. There are several laminoplasty techniques; all aim to alleviate cord compression by reconstructing the spinal canal. Laminoplasty is commonly performed to decompress the spinal cord in patients with degenerative spinal stenosis.

Laminoforaminotomy (also known as posterior discectomy) — The creation of a small window in the lamina to facilitate removal of arthritic bone spurs and herniated disc material pressing on the nerve root as it exits through the foramen. The procedure widens the opening of the foramen so that the nerve exits without being compressed.

Coding Section 

Code	Number	Description
CPT	0092T	Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), each additional interspace, cervical (List separately in addition to code for primary procedure) (code deleted 12/31/14)
	0095T	Removal of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for primary procedure)
	0098T	Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for primary procedure)
	0375T	Total disc arthroplasty (artificial disc), anterior approach, including  discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), cervical, three or more levels  (new code 01/01/15)
	20939 (effective 1/1/2018)	Bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision (List separately in addition to code for primary procedure)
	22548	Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2 (atlas-axis), with or without excision of odontoid process
	22551	Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2
	22552	Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace (List separately in addition to code for separate procedure)
	22554	Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2
	22585	Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (List separately in addition to code for primary procedure)
	22590	Arthrodesis, posterior technique, craniocervical (occiput-C2)
	22595	Arthrodesis, posterior technique, atlas-axis (C1-C2)
	22600	Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment
	22614	Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List separately in addition to code for primary procedure)
	22856	Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); single interspace, cervical
	22858	Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); second level, cervical (List separately in addition to code for primary procedure) (new code 01/01/15)
	22861	Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical
	22862	Total disc arthroplasty (artificial disc), anterior approach
	22864	Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical
	22865	Single Spinal Instrumentation procedures on the Spine (Vertebral Column)
	63001	Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (e.g., spinal stenosis), 1 or 2 vertebral segments; cervical
	63015	Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (e.g., spinal stenosis), more than 2 vertebral segments; cervical
	63020	Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, cervical
	63035	Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additional interspace, cervical or lumbar (List separately in addition to code for primary procedure)
	63040	Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, re-exploration, single interspace; cervical
	63043	Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional cervical interspace (List separately in addition to code for primary procedure)
	63045	Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [e.g., spinal or lateral recess stenosis]), single vertebral segment; cervical
	63048	Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [e.g., spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure)
	63050	Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments;
	63051	Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments; with reconstruction of the posterior bony elements (including the application of bridging bone graft and non-segmental fixation devices [eg, wire, suture, mini-plates], when performed)
	63075	Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace
	63076	Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, each additional interspace (List separately in addition to code for primary procedure)
ICD-9 Diagnosis	722.0	Displacement of cervical intervertebral disc without myelopathy
	722.4	Degeneration of cervical intervertebral disc
ICD-9 Procedure	84.62	Insertion of total spinal disc prosthesis, cervical
	84.66	Revision or replacement of artificial spinal disc prosthesis, cervical
ICD-10-CM (effective 10/1/15)	M5020	Other cervical disc displacement, unspecified cervical region
	M5030	Other cervical disc degeneration, unspecified cervical region
ICD-10-PCS (effective 10/1/15)	0RR30JZ	Open replacement of cervical vertebral disc with synthetic substitute
	0RR50JZ	Open replacement of cervicothoracic vertebral disc with synthetic substitute
Type of Service
Place of Service

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community,and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

History From 2016 Forward     

06/17/2025	Interim review, updating failure of conservative treatment language in ACDF-single level and multi level. Also updating overall formatting and references.
06/03/2024	Annual review, no change to policy intent.
10/11/2023	Interim review to update references. No change to policy intent.
07/10/2023	Annual review, no change to policy intent.
06/26/2023	Updating date.  No other changes.
06192023	Adding codes to coding section 22857, 22862 and 22865.
07/06/2022	Annual review, no change to policy intent.
07/15/2021	Annual review, no change to policy intent.
05/13/2020	Interim review, updating conservative treatment language to include "in the last 6 months." Also changing annual review to July.
03/02/2020	Annual review, no change to policy intent. Restating what conservative treatment is required prior to surgery for clarity. No other changes made.
06/24/2019	Interim review to remove a statement related to smoking. No other changes made.
03/04/2019	Annual review, no change to policy intent. Correcting a typographical error.
07/18/2018	Interim review, removing verbiage related to smoking and nicotine.
03/19/2018	Annual review, no change to policy intent.
12/7/2017	Updating policy with 2018 coding. No other changes.
04/03/2017	Major revision to policy to incorporate artificial disc procedures in policy. Updating title, policy, rationale, references and coding.
03/01/2017	Annual review, no change to policy intent.
03/21/2016	NEW POLICY