Payor
Excellus BCBS
Rubrica tracks 63 sourced coverage rules across 63 CPT codes for Excellus BCBS — covering interventional spine, pain management, ortho spine, and orthopedics. Plan type(s): commercial. 1-state regional policy (sample: ny).
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Every Rubrica record cites a specific Excellus BCBS 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
Excellus BCBS's coverage stance across procedure categories tracked in the Rubrica catalog.
| Category | Rules | Covered | Prior auth | Investigational |
|---|---|---|---|---|
| Other Procedure | 15 | 15 | 14 | 0 |
| Epidural | 6 | 6 | 6 | 0 |
| Facet/MBB | 6 | 6 | 6 | 0 |
| Spine Surgery | 5 | 5 | 5 | 0 |
| Intradiscal Allograft | 4 | 0 | 4 | 4 |
| RFA | 4 | 4 | 4 | 0 |
| Vertebral Augmentation | 3 | 3 | 3 | 0 |
| BVN Ablation | 2 | 0 | 2 | 2 |
| Decompression | 2 | 1 | 2 | 1 |
| Interspinous Spacer | 2 | 0 | 2 | 2 |
| MILD | 2 | 0 | 2 | 2 |
| SCS | 2 | 2 | 2 | 0 |
Top tracked procedures
First 15 CPT codes in the Excellus BCBS catalog. Sign in for verbatim criteria, source links, and the rest of the catalog.
| CPT | Procedure | Coverage |
|---|---|---|
62321 | Cervical/thoracic interlaminar epidural with imaging | Covered |
62323 | Lumbar/sacral (caudal) interlaminar epidural with imaging | Covered |
64479 | TFESI — Cervical/thoracic, single level | Covered |
64480 | TFESI — Cervical/thoracic, each additional level (add-on) | Covered |
64483 | TFESI — Lumbar/sacral, single level | Covered |
64484 | TFESI — Lumbar/sacral, each additional level (add-on) | Covered |
64490 | Cervical/thoracic facet/MBB — single level | Covered |
64491 | Cervical/thoracic facet/MBB — second level (add-on) | Covered |
64492 | Cervical/thoracic facet/MBB — third and any additional level (add-on) | Covered |
64493 | Lumbar/sacral facet/MBB — single level | Covered |
64494 | Lumbar/sacral facet/MBB — second level (add-on) | Covered |
64495 | Lumbar/sacral facet/MBB — third and any additional level (add-on) | Covered |
64633 | RFA — Cervical/thoracic facet, single level | Covered |
64634 | RFA — Cervical/thoracic, each additional level (add-on) | Covered |
64635 | RFA — Lumbar/sacral facet, single level | Covered |
64636 | RFA — Lumbar/sacral, each additional level (add-on) | Covered |
27096 | SI joint injection — anesthetic/steroid with image guidance | Covered |
G0260 | SI joint injection — ASC/HOPD facility code | Covered |
27279 | Minimally invasive sacroiliac joint fusion (transfixing) | Covered |
63650 | SCS — percutaneous lead placement (trial or permanent) | Covered |
63685 | SCS — insertion/replacement of pulse generator | Covered |
22513 | Percutaneous vertebral augmentation (kyphoplasty) — thoracic | Covered |
22514 | Percutaneous vertebral augmentation (kyphoplasty) — thoracic | Covered |
22515 | Percutaneous vertebral augmentation (kyphoplasty) — lumbar add-on | Covered |
62330 | MILD — Percutaneous lumbar decompression with partial removal of ligamentum flavum, single interspace | Not covered |
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