Artificial Cervical Intervertebral Disc 7.01.80

REQUIREMENTS: By October 15, 2025: Billing and prior authorization teams must immediately implement this new policy as the framework for all Excellus BlueCross BlueShield artificial cervical disc replacement requests. Specific actions: - Update prior authorization system to enforce ALL mandatory criteria for both radiculopathy and myelopathy pathways, including: * Age verification (18-60 years only) * Skeletal maturity confirmation * FDA approval verification for specific device used * Single or contiguous two-level limitation at C3-C7 only * No previous surgeries at operative level requirement * Failed conservative treatment documentation (minimum 2 of 3 modalities for 6 weeks each) * Absence of significant cervical instability on imaging * Behavioral health clearance (no unmanaged major depression, chronic pain syndrome, opioid/alcohol use disorder) - Create/update prior auth request templates to require: * Detailed subjective symptom documentation per pathway (radiculopathy vs. myelopathy) * Objective physical exam findings with specific test results * Proof of 6-week conservative treatment trials (prescription analgesics, physical therapy, epidural injections) * Imaging reports (MRI/CT showing neural compression concordant with symptoms, and X-rays documenting absence of instability) * Behavioral health assessment or clearance letter - Train providers and clinical staff on documentation requirements to avoid denials. Emphasize that claims will be DENIED if: * Patient age exceeds 60 years * More than two contiguous levels requested * Previous surgery at operative level documented * Conservative treatment documentation incomplete (less than 2 modalities or less than 6 weeks) * Imaging does not show neural compression concordant with exam findings * Instability indicators present (>3.5mm subluxation, >11° angulation, kyphotic deformity) * Behavioral health disorders unmanaged - For adjacent segment disease pathway specifically: * Verify prior disc arthroplasty performed at least 6 months prior (document date) * Confirm only single-level adjacent replacement requested * Apply same conservative treatment and imaging requirements - Update billing software denial reason codes to reference Policy 7.01.80 criteria when denials occur - Notify all surgeons and orthopedic providers of strict age cutoff (60 years) and two-level limitation, as this likely represents a change from prior practice Consequences: Claims submitted without meeting ALL stated criteria will be denied. This is a comprehensive new policy with no grandfathering of prior authorizations—all requests must comply with 7.01.80 requirements effective immediately upon the date.