Rubrica

Payor

BCBS Massachusetts

Rubrica tracks 63 sourced coverage rules across 63 CPT codes for BCBS Massachusetts — covering interventional spine, pain management, ortho spine, and orthopedics. Plan type(s): commercial. 1-state regional policy (sample: ma).

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63
Sourced rules
63
CPT codes tracked
50
Covered (79%)
61
Prior auth required

Every Rubrica record cites a specific BCBS Massachusetts policy document with last-reviewed date and (where available) verbatim source text. Aggregate coverage breakdown by procedure category is shown below; full payor-specific criteria require sign-in.

Coverage by category

BCBS Massachusetts's coverage stance across procedure categories tracked in the Rubrica catalog.

CategoryRulesCoveredPrior authInvestigational
Other Procedure1515140
Epidural6660
Facet/MBB6460
Spine Surgery5550
RFA4440
ViaDisc4044
Vertebral Augmentation3330
BVN Ablation2121
Decompression2121
Interspinous Device2020
MILD2022
SCS2220

Top tracked procedures

First 15 CPT codes in the BCBS Massachusetts catalog. Sign in for verbatim criteria, source links, and the rest of the catalog.

CPTProcedureCoverage
62321Interlaminar ESI — Cervical/ThoracicCovered
62323Interlaminar ESI — Lumbar/SacralCovered
64479Transforaminal ESI — Cervical/Thoracic (1st level)Covered
64480Transforaminal ESI — Cervical/Thoracic (each additional level)Covered
64483Transforaminal ESI — Lumbar/Sacral (1st level)Covered
64484Transforaminal ESI — Lumbar/Sacral (each additional level)Covered
64490Cervical/Thoracic Facet/MBB (1st level)Covered
64491Cervical/Thoracic Facet/MBB (2nd level)Covered
64492Cervical/Thoracic Facet/MBB (3rd and any additional level)Not covered
64493Lumbar Facet/MBB (1st level)Covered
64494Lumbar Facet/MBB (2nd level)Covered
64495Lumbar Facet/MBB (3rd and any additional level)Not covered
64633RFA — Cervical/Thoracic Facet (1st level)Covered
64634RFA — Cervical/Thoracic Facet (each additional level)Covered
64635RFA — Lumbar Facet (1st level)Covered
64636RFA — Lumbar Facet (each additional level)Covered
27096SI Joint Injection (intra-articular, with imaging guidance)Covered
G0260SI Joint Injection (HCPCS — ASC/hospital outpatient setting)Covered
27279Percutaneous SI Joint Fusion (minimally invasive, transfixing device)Covered
63650SCS — Percutaneous Trial Lead PlacementCovered
63685SCS — Generator/Receiver Insertion (permanent implant)Covered
22513Percutaneous Vertebral Augmentation — Thoracic (1st VB)Covered
22514Percutaneous Vertebral Augmentation — Lumbar (1st VB)Covered
22515Percutaneous Vertebral Augmentation — each additional VBCovered
62330MILD — Percutaneous Lumbar Decompression (1st interspace)Not covered

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