Description
Operative treatment is indicated only when the natural history of surgically treated lesions is better than the natural history for non-operatively treated lesions. All operative interventions must be based on a positive correlation with clinical findings, the natural history of the disease, the clinical course, and diagnostic tests or imaging results. All individuals being considered for surgical intervention should receive a comprehensive neuromusculoskeletal examination to identify pain generators that may either respond to non-surgical techniques or may be refractory to surgical intervention.

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.
• The guideline criteria in the following sections were developed utilizing evidence-based and peer-reviewed resources from medical publications and societal organization guidelines as well as from widely accepted standard of care, best practice recommendations.

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.

Special Note
In order for surgeries to be considered medically necessary there must be clear medical records that demonstrate a clear surgical plan that matches the request for surgery.

BACKGROUND
*Conservative Treatment
Non-operative conservative treatment should include a multimodality approach consisting of at least one (1) active and one (1) inactive component targeting the affected spinal region.

• 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)

Policy 
IINDICATIONS
Anterior Cervical Discectomy with Fusion (ACDF) - Single Level
When one of the two following criteria are met ^(1–8):

• Positive clinical findings of myelopathy with evidence of progressive neurologic deficits consistent with spinal cord compression - immediate surgical evaluation is indicated. Symptoms may include⁽⁷⁾:
  • 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 ^(6–8):

• 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^(1,2,6,9):

• 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 3.5 mm anterior subluxation in association with radicular/cord dysfunction
  • Subluxation at the (C1) level of the atlantodental interval of more than 3 mm in an adult and 5 mm 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^(1–8):

• 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 ^(6–8):

• 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^(1,2,6,9):

• 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 3.5 mm anterior subluxation in association with radicular/cord dysfunction
  • Subluxation at the (C1) level of the atlantodental interval of more than 3 mm in an adult and 5 mm 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 (CPDF) - Single Level
When one of the two following criteria are met ^(1–8,11):

• 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 ^(8,12,13):

• Cervical radiculopathy or myelopathy from ruptured disc, spondylosis, spinal instability, or deformity OR documented pseudarthrosis of prior ACDF/Cervical Artificial Disc Replacement (CADR) - one of the most common indications for a Single Level or Multi Levels CPDF is a failed anterior procedure
• 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 ^(1,2,6,9,11):

• 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 3.5 mm anterior subluxation in association with radicular/cord dysfunction
  • Subluxation at the (C1) level of the atlantodental interval of more than 3 mm in an adult and 5 mm 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 (CPDF) – Multiple Levels
When one of the two following criteria are met ^(1–8,11):

• 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 ^(8,12,13):

• Cervical radiculopathy or myelopathy from ruptured disc, spondylosis, spinal instability, or deformity OR documented pseudarthrosis of prior anterior ACDF/CADR surgery
• 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 ^(1,2,6,9,11):

• 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 3.5 mm anterior subluxation in association with radicular/cord dysfunction
  • Subluxation at the (C1) level of the atlantodental interval of more than 3 mm in an adult and 5 mm 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 ^(14,15):

• 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*^{(1,2,4–8,16)}:

• 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^(1,2,6,16):

• 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) ^(8,17,18)
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) or a failed Cervical Disc Arthroplasty Implant as evidenced by a post-operative image showing a previously placed cervical disc arthroplasty noted to have implant malposition or failure as evidenced by one or more of the following ^(19,20):
  • Subsidence
  • Loosening
  • Infection
  • Dislocation
  • Subluxation
  • Vertebral body fracture
  • Dislodgement
• 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 3 mm 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

Cervical Fusion Without Decompression
Cervical fusion without decompression will be reviewed on a case-by-case basis. A traumatic instability due to Down Syndrome-related spinal deformity, rheumatoid arthritis, or basilar invagination are uncommon, but may require cervical fusion.

Cervical Anterior Decompression (Without Fusion) 
All requests for anterior decompression without fusion will be reviewed on a case-by-case basis.

RISK FACTORS AND CONSIDERATIONS ^(21–24)

• 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 kg/m2. 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. Cessation must be confirmed by a negative cotinine test prior to surgery approval.
• 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.

SUMMARY OF EVIDENCE
Comparison of anterior and posterior approaches for functional improvement in cervical myelopathy: A systematic review and meta-analysis of 33,025 patients ⁽¹¹⁾
Study Design: Systematic review and meta-analysis. 
Target Population: 33,025 patients with cervical myelopathy. 
Key Factors:

• Objective: To compare the risks and benefits of anterior and posterior surgical techniques for cervical myelopathy.
• Methods: Systematic search across databases including PubMed, Scopus, and Web of Science. Studies were selected based on predefined inclusion criteria and assessed using NOS and Rob-2 tools.
• Results: The anterior approach was associated with better neurological recovery, greater improvement in Cobb’s angle, and statistically significant decreases in VAS and NDI scales compared to the posterior approach. It also led to fewer complications, less pain, reduced blood loss, and shorter hospital stays.
• Conclusions: The anterior approach for cervical myelopathy may improve nerve function, correct spinal curvature more effectively, and lead to fewer complications compared to the posterior approach.

Comparison of Anterior Surgery Versus Posterior Surgery for the Treatment of Multilevel Cervical Spondylotic Myelopathy: A Meta-Analysis ⁽⁴⁾
Study Design: Meta-analysis. 
Target Population: 2,712 patients with multilevel cervical spondylotic myelopathy (MCSM). 
Key Factors:

• Objective: To evaluate the impact of anterior versus posterior surgical approaches on outcomes in MCSM.
• Methods: Comprehensive search across electronic databases including MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials. Studies were assessed using the Newcastle-Ottawa Scale score.
• Results: No significant difference between the two groups in preoperative and postoperative JOA scores, JOA recovery rate, or neck VAS score. However, the anterior surgery group had significantly lower NDI scores, blood loss, and shorter length of stay, but higher rates of complications. The anterior surgery group also had better recovery of cervical lordosis but limited postoperative mobility.
• Conclusion: No clear advantage of one surgical approach over the other for MCSM in terms of neurological function recovery. The anterior approach was associated with improved NDI scores, lower blood loss, shorter length of stay, and better recovery of cervical lordosis.

The Essence of Clinical Practice Guidelines for Cervical Spondylotic Myelopathy, 2020⁽⁷⁾
Study Design: Clinical practice guidelines. 
Target Population: Patients with cervical spondylotic myelopathy (CSM). 
Key Factors:

• Objective: To provide guidelines for the management of CSM.
• Epidemiology: CSM is common in men aged 50 years and older, with an incidence of several people per 100,000 population.
• Natural History: Patients with severe and progressive symptoms need surgery. Mild cases require appropriate care and monitoring.
• Pathology: CSM arises from static and dynamic compression factors affecting the spinal cord, with circulatory disturbances also involved.
• Diagnosis: Sensory disturbance of the upper limbs and motor dysfunction of the upper and lower limbs are common. Imaging studies and neurological examination are important for proper diagnosis.
• Treatment: Conservative treatment is primarily for mild cases. Surgery is suitable for progressive myelopathy. Surgical methods include anterior decompression and fusion (ADF), laminoplasty, and posterior decompression with fusion (PDF).
• Prognosis: Good postoperative recovery of lower limb motor function leads to a sufficient prognosis

ANALYSIS OF EVIDENCE
Shared Findings ^(4,7,11):

• Both Aleid et al. 2025 and Bao et al. 2025 agree that the anterior approach generally results in lower blood loss and shorter hospital stays.
• All three studies acknowledge that both anterior and posterior approaches have their own sets of advantages and disadvantages, and the choice of approach should be tailored to the individual patient’s condition 

Differing Findings ^(4,7,11):

• Aleid et al. 2025 emphasizes the superiority of the anterior approach in terms of neurological recovery and functional improvement.
• Bao et al. 2025 highlights that there is no clear advantage of one approach over the other in terms of neurological function recovery, but the anterior approach has better outcomes in terms of NDI scores and cervical lordosis.
• Nagoshi 2024 provides a more balanced view, recommending that the choice of surgical method should be based on the specific pathology and patient condition, without favoring one approach over the other.

In summary, while there are some differences in the conclusions drawn by these studies, they all highlight the importance of tailoring the surgical approach to the individual patient's condition and the specific pathology involved. The anterior approach generally shows better outcomes in terms of blood loss, hospital stay, and cervical lordosis, but it also has higher complication rates compared to the posterior approach. The guidelines emphasize the need for a balanced and patient-specific approach to treatment.

References 

1. Guo S, Lin T, Wu R, Wang Z, Chen G, Liu W. The Pre-Operative Duration of Symptoms: The Most Important Predictor of Post-Operative Efficacy in Patients with Degenerative Cervical Myelopathy. Brain Sci. 2022;12(8):1088. doi:10.3390/brainsci12081088
2. Chen X, Fan Y, Chen J, Tu H. Clinical efficacy and complications of 10 surgical interventions for cervical ossification of the posterior longitudinal ligament: an updated systematic review and network meta-analysis. J Orthop Surg Res. 2025;20(1). doi:10.1186/s13018-025-05878-x
3. Luyao H, Xiaoxiao Y, Tianxiao F, Yuandong L, Ping Wang. Management of Cervical Spondylotic Radiculopathy: A Systematic review. Global Spine J. 2022;12(8):1912-1924. doi:10.1177/21925682221075290
4. Bao X, Ren K, Guo W, et al. Comparison of Anterior Surgery Versus Posterior Surgery for the Treatment of Multilevel Cervical Spondylotic Myelopathy: A Meta-Analysis. Clin Spine Surg. 2025;38(7):333-344. doi:10.1097/BSD.0000000000001778
5. Park DK, Jenne JW, Bode KS, Throckmorton TW, Fischer SJ, Jenis LG. Cervical Spondylotic Myelopathy: Surgical Treatment Options. OrthoInfo. 2022;(February 7). https://orthoinfo.aaos.org/en/treatment/cervical-spondylotic-myelopathysurgical-treatment-options/
6. Fehlings MG, Tetreault LA, Riew KD, et al. A Clinical Practice Guideline for the Management of Patients With Degenerative Cervical Myelopathy: Recommendations for Patients With Mild, Moderate, and Severe Disease and Nonmyelopathic Patients With Evidence of Cord Compression. Global Spine J. 2017;7(3_supplement):70S-83S. doi:10.1177/2192568217701914
7. Nagoshi N, Fujiwara Y, Iizuka Y, et al. The Essence of Clinical Practice Guidelines for Cervical Spondylotic Myelopathy, 2020. Spine Surg Relat Res. 2024;8(2):119-132. doi:10.22603/ssrr.2022-0229
8. North American Spine Society. Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders. NASS. Published online 2010. doi:https://www.spine.org/Portals/0/Assets/Downloads/ResearchClinicalCare/Guidelines/CervicalRadiculopathy.pdf
9. Karamian BA, Schroeder GD, Lambrechts MJ, et al. An international validation of the AO spine subaxial injury classification system. European Spine Journal. 2023;32(1):46-54. doi:10.1007/s00586-022-07467-6
10. Khosravi S, Farahbakhsh F, Hesari M, et al. Predictors of Outcome After Surgical Decompression for mild degenerative Cervical Myelopathy -A Systematic Review. Global Spine J. 2024;14(2):697-706. doi:10.1177/21925682231164346
11. Aleid A, Aldanyowi S, Alaidarous H, Aleid Z, Alharthi A, Al Mutair A. Comparison of anterior and posterior approaches for functional improvement in cervical myelopathy: A systematic review and meta-analysis of 33,025 patients. North American Spine Society Journal. 2025;22. doi:10.1016/j.xnsj. 2024.100567
12. Steinhaus ME, York PJ, Bronheim RS, Yang J, Lovecchio F, Kim HJ. Outcomes of Revision Surgery for Pseudarthrosis After Anterior Cervical Fusion: Case Series and Systematic Review. Global Spine J. 2020;10(5):559-570. doi:10.1177/2192568219863808
13. McAnany SJ, Baird EO, Overley SC, Kim JS, Qureshi SA, Anderson PA. A meta-analysis of the clinical and fusion results following treatment of symptomatic cervical pseudarthrosis. Global Spine J. 2014;5(2):148-155. doi:10.1055/s-0035-1544176
14. 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. 2010;1(03):45-50. doi:10.1055/s-0030-1267067
15. Harrop JS, Gonzalez GA, Qasba RK, et al. Does axial cervical pain improve with surgical fusion? A meta-analysis. J Neurosurg Spine. Published online May 1, 2023:1-10. doi:10.3171/2023.4.SPINE23185
16. Revesz DF, Charalampidis A, Gerdhem P. Effectiveness of laminectomy with fusion and laminectomy alone in degenerative cervical myelopathy. European Spine Journal. 2022;31(5):1300-1308. doi:10.1007/s00586-022-07159-1
17. Lee JH, Lee YJ, Chang MC, Lee JH. Clinical Effectiveness of Artificial Disc Replacement in Comparison With Anterior Cervical Discectomy and Fusion in the Patients With Cervical Myelopathy: Systematic Review and Meta-analysis. Neurospine. 2023;20(3):1047-1060. doi:10.14245/ns. 2346498.249
18. Nunley P, Frank K, Stone M. Patient Selection in Cervical Disc Arthroplasty. Int J Spine Surg. 2020;14(s2):S29-S35. doi:10.14444/7088
19. Joaquim AF, Lee NJ, Riew KD. Revision Surgeries at the Index Level After Cervical Disc Arthroplasty – A Systematic Review. Neurospine. 2021;18(1):34-44. doi:10.14245/ns. 2040454.227
20. Kong CG, Park JB. Reoperation Strategy for Failure of Cervical Disc Arthroplasty at Index and Adjacent Levels. J Clin Med. 2025;14(6):2038. doi:10.3390/jcm14062038
21. Badiee RK, Mayer R, Pennicooke B, Chou D, Mummaneni P V., Tan LA. Complications following posterior cervical decompression and fusion: a review of incidence, risk factors, and prevention strategies. Journal of Spine Surgery. 2020;6(1):323-333. doi:10.21037/jss.2019.11.01
22. Yee TJ, Swong K, Park P. Complications of anterior cervical spine surgery: A systematic review of the literature. Journal of Spine Surgery. 2020;6(1):302-322. doi:10.21037/jss.2020.01.14
23. Rajesh N, Moudgil-Joshi J, Kaliaperumal C. Smoking and degenerative spinal disease: A systematic review. Brain and Spine. 2022;2. doi:10.1016/j.bas. 2022.100916
24. Rajaee SS, Kanim LEA, Bae HW. National trends in revision spinal fusion in the USA. Bone Joint J. 2014;96-B(6):807-816. doi:10.1302/0301-620X.96B6.31149

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	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     

06/09/2026	Annual review, updating policy for clarity and consistency.  Adding documentation of failed prior anterior cervical surgeries to indication for CPDF and adding negative nicotine lab test requirements for smokers prior to spine surgery approval.  Also updating general information, adding special note, and adding rationale.
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