Payor
California Medicaid (Medi-Cal)
Rubrica tracks 100 sourced coverage rules across 100 CPT codes for California Medicaid (Medi-Cal) — covering interventional spine, pain management, ortho spine, and orthopedics. Plan type(s): Medicaid, medicaid. 1-state regional policy (sample: ca).
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Every Rubrica record cites a specific California Medicaid (Medi-Cal) 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
California Medicaid (Medi-Cal)'s coverage stance across procedure categories tracked in the Rubrica catalog.
| Category | Rules | Covered | Prior auth | Investigational |
|---|---|---|---|---|
| Diagnostic | 13 | 13 | 1 | 0 |
| Epidural | 11 | 10 | 10 | 0 |
| RFA | 9 | 9 | 9 | 0 |
| Vertebral Augmentation | 9 | 9 | 9 | 0 |
| Peripheral Joint/Tendon | 7 | 7 | 7 | 0 |
| Peripheral Nerve Block | 7 | 7 | 7 | 0 |
| SCS | 7 | 7 | 6 | 0 |
| Other Procedure | 5 | 1 | 0 | 0 |
| Spine Surgery | 5 | 5 | 5 | 0 |
| HCPCS Drug | 4 | 4 | 4 | 0 |
| Intrathecal Pump | 4 | 4 | 2 | 0 |
| Botulinum Toxin | 3 | 3 | 3 | 0 |
Top tracked procedures
First 15 CPT codes in the California Medicaid (Medi-Cal) catalog. Sign in for verbatim criteria, source links, and the rest of the catalog.
| CPT | Procedure | Coverage |
|---|---|---|
27447 | Total Knee Arthroplasty (TKA) | Covered |
27130 | Total Hip Arthroplasty (THA) | Covered |
23472 | Total Shoulder Arthroplasty (TSA / Reverse TSA) | Covered |
29827 | Arthroscopic Rotator Cuff Repair | Covered |
29888 | Arthroscopic ACL Reconstruction | Covered |
22551 | ACDF — Anterior Cervical Discectomy and Fusion | Covered |
22612 | PLF — Posterior Lumbar Fusion (Posterolateral) | Covered |
22558 | ALIF — Anterior Lumbar Interbody Fusion | Covered |
63030 | Laminotomy with Disc Excision — Lumbar | Covered |
63047 | Laminectomy with Facetectomy and Foraminotomy — Lumbar | Covered |
0200T | Percutaneous sacroiliac SI joint fusion | Covered |
0201T | Bilateral percutaneous sacroiliac SI joint fusion | Covered |
0232T | Epidural lysis of adhesions | Covered |
0275T | Percutaneous vertebral fracture augmentation | Covered |
0627T | Atherectomy, coronary artery | Not covered |
0629T | Transcatheter mitral valve therapy | Not covered |
0779T | Bronchial thermoplasty | Not covered |
11980 | Subcutaneous hormone pellet implantation | Not covered |
20526 | Percutaneous skeletal fixation of fracture | Covered |
20552 | Injection, therapeutic, including imaging guidance | Covered |
20553 | Injection, therapeutic, including ultrasound guidance (muscular injections) | Covered |
20610 | Arthrocentesis, major joint (shoulder, hip, knee, ankle) | Covered |
20611 | Arthrocentesis, major joint (shoulder, hip, knee, ankle), with therapeutic injection | Covered |
22510 | Percutaneous vertebroplasty, cervical | Covered |
22511 | Percutaneous vertebroplasty, thoracic | Covered |
See every policy for California Medicaid (Medi-Cal).
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