Artificial disc replacement (ADR)* - Re-review

* Artificial Disc Replacement is the same as Total Disc Arthroplasty (TDA)

Lumbar ADR

Coverage Decision: Not covered

Lumbar artificial disc replacement is not a covered benefit.

Cervical ADR

Coverage Decision: Covered with conditions

Conditions of coverage:

Cervical artificial disc replacement is covered for accepted conditions when the following criteria are met:

  • Patients must meet FDA approved indications for use and not have any contraindications. FDA approval is device specific but includes.
    • Skeletally mature patients
    • Disc replacement following one- or two-level discectomy for intractable symptomatic radiculopathy or myelopathy confirmed by patient findings and imaging.
  • Patients must have advanced imaging and clinical evidence of corresponding nerve root or spinal cord compression and have failed or be inappropriate for non-operative care. For two-level procedures, objective evidence of radiculopathy, myelopathy or spinal cord compression at two consecutive levels is required.

For detailed criteria, please refer to the L&I medical treatment guideline Diagnosis and Treatment of Cervical Radiculopathy and Myelopathy.

Background Information

The State Health Technology Clinical Committee (HTCC) originally reviewed ADR in October 2008, and their decision to cover ADR was adopted by L&I in March 2009. The Industrial Insurance Medical Advisory Committee (IIMAC) subcommittee for cervical spinal surgery drafted a new guideline, Diagnosis and Treatment of Cervical Radiculopathy and Myelopathy, which includes two-level cervical ADR. The guideline was adopted in September 2014. 

The HTCC re-reviewed the ADR technology in January 2017 and in March 2017 finalized their determination to cover cervical ADR, including two-level ADR with conditions, but not cover lumbar ADR. Complete information on this HTCC determination is available at: http://www.hca.wa.gov/about-hca/health-technology-assessment/health-technology-reviews.

In adopting this HTCC coverage determination, the Department has concluded that the determination does not conflict with any state statute. Any coverage for investigational treatment would be considered per WAC 296-20-02850.  Any coverage for health technologies that have a FDA Humanitarian Device Exemption status would be considered per RCW 70.14.120 (1) (b).

Implementation of the Coverage Determination

All requests for ADR require prior authorization. The service may be covered only for care of a condition accepted on or related to the claim.

For billing information, please refer to L&I Fee Schedules and Payment Policies (MARFS).

For State Fund Claims

Please contact Utilization Review Vendor (Comagine): http://www.lni.wa.gov/ClaimsIns/Providers/AuthRef/UtilReview/default.asp

For Self-Insured Claims

Please contact the self-insured employer (SIE) or their third party administrator (TPA). For a list of SIE/TPAs, go to: http://www.Lni.wa.gov/ClaimsIns/Insurance/SelfInsure/EmpList/Default.asp


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