CommercialPrior AuthHigh impact
Intervertebral Disc Prostheses (CPB 0591, reviewed 2026-07-13)
Aetna·Neurosurgery, Orthopedics, Pain Management·Medical Policy
Effective date
Jul 13, 2026
We identified it
Aug 19, 2026
Summary
Aetna has updated its Intervertebral Disc Prostheses policy (CPB 0591) effective July 13, 2026, establishing specific medical necessity criteria for cervical and lumbar disc arthroplasty, including age limits, device-specific approvals, conservative treatment requirements, imaging specifications, and bone density/metabolic control standards. Billing teams must verify patient age, device type, clinical documentation, and pre-operative testing before submitting claims to avoid denials.
Action Required
By July 13, 2026: Billing team must implement the following verification steps BEFORE submitting disc arthroplasty claims: (1) Verify patient age matches device-specific age limits (e.g., Mobi-C requires age 21-67 for cervical single level); (2) Confirm imaging studies (MRI/CT) performed within past year document stenosis grade and rule out contraindications; (3) Verify 6+ weeks recent conservative management documentation (PT notes, claims history within past year) or obtain waiver documentation for emergent conditions; (4) For diabetic patients, confirm HbA1c <8% within 3 months prior to surgery (unless emergent: myelopathy, cauda equina, severe weakness 4-/5 or progressive weakness); (5) For patients 60+, confirm DEXA scan (T-score ≥-1.0) within past year; (6) For lumbar: confirm single-level disease at L3-4, L4-5, or L5-S1, age 18-60, VAS >5, and no contraindications (spondylolisthesis >3mm, stenosis, scoliosis >11°, fracture, infection, etc.); (7) Attach all required documentation to pre-authorization request. Update Prior Auth checklist in billing system to require these fields before claim submission. Inform providers of new documentation requirements via encounter template updates. Claims submitted without verification will be denied. Designate Prior Auth specialist to review each case against policy criteria before authorization.