Payor
Health Partners Plans / Jefferson Health Plans — PA HealthChoices
Rubrica tracks 101 sourced coverage rules across 101 CPT codes for Health Partners Plans / Jefferson Health Plans — PA HealthChoices — covering interventional spine, pain management, ortho spine, and orthopedics. Plan type(s): Medicaid. 1-state regional policy (sample: pa).
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Every Rubrica record cites a specific Health Partners Plans / Jefferson Health Plans — PA HealthChoices 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
Health Partners Plans / Jefferson Health Plans — PA HealthChoices's coverage stance across procedure categories tracked in the Rubrica catalog.
| Category | Rules | Covered | Prior auth | Investigational |
|---|---|---|---|---|
| Diagnostic | 14 | 14 | 3 | 0 |
| Intradiscal | 8 | 4 | 8 | 4 |
| Vertebral Augmentation | 8 | 6 | 8 | 2 |
| SCS | 7 | 7 | 6 | 0 |
| Epidural | 6 | 6 | 6 | 0 |
| Facet/MBB | 6 | 4 | 6 | 0 |
| Intrathecal Pump | 6 | 6 | 4 | 0 |
| HCPCS Drug | 5 | 5 | 5 | 0 |
| RFA | 5 | 5 | 5 | 0 |
| Botulinum Toxin | 4 | 4 | 4 | 0 |
| Interspinous Device | 4 | 2 | 4 | 2 |
| PNS | 4 | 4 | 4 | 0 |
Top tracked procedures
First 15 CPT codes in the Health Partners Plans / Jefferson Health Plans — PA HealthChoices catalog. Sign in for verbatim criteria, source links, and the rest of the catalog.
| CPT | Procedure | Coverage |
|---|---|---|
62321 | Interlaminar ESI — Cervical/Thoracic | Covered |
62323 | Interlaminar ESI — Lumbar | Covered |
64479 | TFESI — Cervical/Thoracic (1st level) | Covered |
64480 | TFESI — Cervical/Thoracic (add'l level) | Covered |
64483 | TFESI — Lumbar/Sacral (1st level) | Covered |
64484 | TFESI — Lumbar/Sacral (add'l level) | Covered |
64490 | Facet/MBB — Cervical/Thoracic (1st level) | Covered |
64491 | Facet/MBB — Cervical/Thoracic (2nd level) | Covered |
64492 | Facet/MBB — Cervical/Thoracic (3rd+ level) | Not covered |
64493 | Facet/MBB — Lumbar/Sacral (1st level) | Covered |
64494 | Facet/MBB — Lumbar/Sacral (2nd level) | Covered |
64495 | Facet/MBB — Lumbar/Sacral (3rd+ level) | Not covered |
64633 | RFA — Cervical/Thoracic Facet (1st level) | Covered |
64634 | RFA — Cervical/Thoracic Facet (add'l level) | Covered |
64635 | RFA — Lumbar/Sacral Facet (1st level) | Covered |
64636 | RFA — Lumbar/Sacral Facet (add'l level) | Covered |
27096 | Sacroiliac Joint Injection (CPT) | Covered |
G0260 | SI Joint Injection (Medicare ASC HCPCS) | Covered |
64451 | SI Joint Nerve Block (S1–S3 lateral branches) | Covered |
64625 | SI Joint RFA (lateral branches) | Covered |
27279 | SI Fusion — Minimally Invasive | Covered |
27280 | SI Fusion — Open | Covered |
63650 | SCS — Percutaneous Trial | Covered |
63661 | SCS — Lead Revision/Removal (percutaneous) | Covered |
63685 | SCS — Permanent Implant (IPG) | Covered |
See every policy for Health Partners Plans / Jefferson Health Plans — PA HealthChoices.
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