Payor
Johns Hopkins US Family Health Plan
Rubrica tracks 32 sourced coverage rules across 32 CPT codes for Johns Hopkins US Family Health Plan — covering interventional spine, pain management, ortho spine, and orthopedics. Plan type(s): Tricare. 4-state regional policy (sample: dc, de, md, pa).
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Every Rubrica record cites a specific Johns Hopkins US Family Health Plan 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
Johns Hopkins US Family Health Plan's coverage stance across procedure categories tracked in the Rubrica catalog.
| Category | Rules | Covered | Prior auth | Investigational |
|---|---|---|---|---|
| Intradiscal | 8 | 6 | 8 | 0 |
| Vertebral Augmentation | 5 | 3 | 5 | 0 |
| Intrathecal Pump | 4 | 4 | 4 | 0 |
| PNS | 4 | 4 | 4 | 0 |
| SCS | 4 | 4 | 4 | 0 |
| Decompression | 3 | 3 | 3 | 0 |
| Interspinous Device | 2 | 2 | 2 | 0 |
| SI Fusion | 2 | 2 | 2 | 0 |
Top tracked procedures
First 15 CPT codes in the Johns Hopkins US Family Health Plan catalog. Sign in for verbatim criteria, source links, and the rest of the catalog.
| CPT | Procedure | Coverage |
|---|---|---|
63650 | SCS — Percutaneous Trial | Covered |
63685 | SCS — Permanent Implant (IPG) | Covered |
63661 | SCS — Lead Revision/Removal (percutaneous) | Covered |
63688 | SCS — Generator Revision/Removal | Covered |
0275T | MILD — Percutaneous Image-Guided Lumbar Decompression (DELETED 2026) | Covered |
62330 | MILD — Percutaneous Lumbar Decompression (no image guidance) | Covered |
62331 | MILD — Percutaneous Lumbar Decompression (with image guidance) | Covered |
64555 | PNS — Percutaneous Lead Trial/Placement | Covered |
64580 | PNS — Open Electrode Placement (neuromuscular) | Covered |
64590 | PNS — Generator Insertion | Covered |
64595 | PNS — Generator Revision/Removal | Covered |
0627T | ViaDisc / Disc Allograft — Lumbar (1st) | Covered |
0628T | ViaDisc — Lumbar (additional level) | Covered |
0629T | ViaDisc — Cervical/Thoracic (1st) | Covered |
0630T | ViaDisc — Cervical/Thoracic (add'l) | Covered |
64628 | Intracept — Basivertebral Nerve Ablation (1st) | Covered |
64629 | Intracept — BVN Ablation (add'l) | Covered |
62380 | Endoscopic Lumbar Decompression | Not covered |
0200T | Sacroplasty — Unilateral | Not covered |
0201T | Sacroplasty — Bilateral | Not covered |
22513 | Kyphoplasty — Thoracic (1st level) | Covered |
22514 | Kyphoplasty — Lumbar (1st level) | Covered |
22515 | Kyphoplasty — Each Additional Level | Covered |
27279 | SI Fusion — Minimally Invasive | Covered |
27280 | SI Fusion — Open | Covered |
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