Cervical Discectomy Checklist

Published 06/04/2021

A Cervical Discectomy is a type of neck surgery that involves removing a damaged disc to relieve spinal cord or nerve root pressure and alleviate corresponding pain, weakness, numbness, and tingling. Documentation Requirements for cervical discectomy includes:

 

Yes

No

Indicate if this request is an expedited review for cervical discectomy

   

Documentation submitted supports a condition or diagnosis for cervical discectomy

 

 

The procedure requested is indicated for cervical generative disc disease C3 to C7

 

 

Documentation supports that conservative treatments have been attempted for 6 weeks for intractable cervical pain or myelopathy

 

 

The patient has severe or rapidly progressive symptoms of nerve root or spinal cord compression requiring immediate surgical intervention

 

 

Documentation submitted support pain characteristics and/or interference with activities of daily living (ADLs)

 

 

Physician order for the procedure/device

 

 

Documentation supports that conservative treatments have been tried and failed

Oral steroid therapy

   

Analgesics

   

Physical therapies

   

Epidural block

   

Reduced activity

 

 

Other — Please list

 

 

Documentation includes radiological evidence of nerve root or spinal cord compression (CT scan, MRI or Myelography)

   

 

 

 

Does the beneficiary have any contraindications to cervical discectomy?

   

Extreme obesity (BMI of 40 of greater)

   

Significant cervical anatomical deformity

   

Allergy or sensitivity to implant materials

 

 

Active systemic infection at the operating site

 

 

Osteoporosis or osteopenia

 

 

Marked cervical instability

 

 

Severe spondylosis

 

 

Clinically compromised vertebral bodies at affected level