Ortho Spine · Policy Library
Spine surgery coverage, without surprises.
Part of the Rubrica clinical policy library — the largest sourced collection in spine surgery. Spine surgery prior auth is unforgiving: a single missed criterion can mean a denial six weeks before a scheduled fusion, or a rework cycle that costs the practice $4,000 in administrative labor. Every payor's spine-surgery coverage rule with verbatim source text — fusion (anterior, posterior, combined), decompression, disc arthroplasty, instrumentation, bone graft, and navigation.
Free with practitioner sign-in — magic-link email auth, no credit card.
Built for orthopedic spine surgeons, neurosurgeons, and the surgical-coordinator and prior-auth teams behind them. From a single-level lumbar fusion (CPT 22612) to a complex multi-level instrumented decompression with arthrodesis, the criteria are tracked across all 7 Medicare MACs, all major commercial payors, and all 50-state Medicaid programs.
Top procedures by payor coverage
Eight procedures with the broadest payor coverage in this specialty. Click through any of them in the live app for the full coverage breakdown.
| CPT | Procedure | Coverage breadth |
|---|---|---|
27279 | SI Fusion — Minimally Invasive | 137 payors |
22513 | Kyphoplasty — Thoracic (1st level) | 136 payors |
22514 | Kyphoplasty — Lumbar (1st level) | 136 payors |
62330 | MILD — Percutaneous Lumbar Decompression (no image guidance) | 116 payors |
62331 | MILD — Percutaneous Lumbar Decompression (with image guidance) | 116 payors |
62380 | Endoscopic Lumbar Decompression | 116 payors |
62287 | Percutaneous Disc Decompression — Fluoroscopic | 116 payors |
22515 | Kyphoplasty — Each Additional Level | 100 payors |
Full catalog at /library — 82 procedures, 82 unique CPTs.
Payors tracked
Top 12 payors by number of rules in this specialty. Each rule is sourced to a specific policy document with last-reviewed date.
Plus 140 more payors. Full per-payor drill-down at #payor=<name>.
Coverage Q&A
Common prior-auth questions for this specialty. Each answer is grounded in a specific policy document; live decisions are available at rubricamedical.com/#app.
Lumbar posterior fusion (CPT 22612)
Universally requires ≥6 months of conservative care, advanced imaging within 12 months, and documentation of mechanical instability or stenosis with neurogenic claudication. Aetna CPB 0743 and Cigna CCP 0303 are the standard references; CMS NCD 150.10 governs Medicare.
Cervical disc arthroplasty (CPT 22856)
Many commercial payors cover one- or two-level CDA per FDA-approved devices; multi-level still investigational at most plans. BCBS family plans split — some cover, some don't — making the per-payor drill-down essential.
SI joint fusion (CPT 27279)
The most contentious code in the catalog. Aetna, Cigna, UHC commercial cover with strict criteria (3-of-5 provocation maneuvers, diagnostic block ≥75% relief, conservative care). Medicare MACs follow LCD L38570 family. Required documentation is extensive.
Decompression — laminectomy (CPT 63047)
Covered universally with imaging concordance and ≥6 weeks failed conservative care; documentation must establish neurogenic claudication or radiculopathy correlating with the imaged level.
How we encode coverage
Every record is keyed by payor + CPT + region, sourced to a public policy
document, dated by last-reviewed date, and tagged with verbatim source quotes
where available. Records older than 18 months are flagged stale; records that
couldn't be authoritatively confirmed are flagged needs_verification
and surfaced behind a warning.
The decision engine compares clinical context against criteria sub-objects — conservative care, imaging concordance, prior-procedure documentation, and repeat-procedure thresholds — and returns a likelihood plus a 0–100 denial-risk score with the top three drivers. Read the full methodology at /methodology.
Run a real check.
Pick a payor, enter the clinical context, get a sourced answer with denial risk and the missing documentation list — in seconds.
Run a check →