All PlansPrior AuthHigh impact
Artificial Intervertebral Disc
Regence BlueShield·Neurosurgery, Orthopedics, General Surgery +2 more·Medical Policy
Effective date
Oct 1, 2026
We identified it
Jul 7, 2026
Summary
This is a new medical policy (effective October 1, 2026) establishing coverage criteria for artificial intervertebral disc replacement surgery in cervical and lumbar regions. The policy defines specific medical necessity requirements, patient eligibility criteria (age 18-60), imaging standards, conservative therapy documentation requirements, and contraindications. Billing teams must prepare to implement prior authorization workflows and documentation requirements before the effective date.
Action Required
Before October 1, 2026: (1) Billing team must update prior authorization system to require submission of all documentation listed in 'List of Information Needed for Review' section (H&P, imaging reports, device name, conservative therapy documentation, symptom response). (2) Create authorization checklist templates for cervical disc replacement (Section I criteria A-H) and lumbar disc replacement (Section III criteria A-H) in billing software. (3) Providers must update encounter forms and clinical documentation templates to capture: patient age, skeletal maturity status, specific operative levels (C3-C7 for cervical; L3-4, L4-5, L5-S1 for lumbar), MRI/CT imaging findings (stenosis severity, nerve compression documentation), conservative therapy attempts with specific dates (minimum 6 weeks), and any contraindications listed. (4) Front office staff must screen requests to reject non-FDA-approved devices before processing. (5) Update denial protocols: claims for simultaneous multi-level cervical procedures, lumbar procedures with planned hybrid fusion, patients outside age 18-60 range, or procedures lacking required documentation must be denied. (6) Communicate with surgical practices that revision/replacement procedures are explicitly NOT covered under this policy. Failure to obtain proper authorization and documentation will result in claim denials.