Payor
Pennsylvania Medical Assistance
Rubrica tracks 100 sourced coverage rules across 100 CPT codes for Pennsylvania Medical Assistance — covering interventional spine, pain management, ortho spine, and orthopedics. Plan type(s): Medicaid, medicaid. 1-state regional policy (sample: pa).
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Every Rubrica record cites a specific Pennsylvania Medical Assistance 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
Pennsylvania Medical Assistance's coverage stance across procedure categories tracked in the Rubrica catalog.
| Category | Rules | Covered | Prior auth | Investigational |
|---|---|---|---|---|
| Diagnostic | 14 | 14 | 11 | 0 |
| Vertebral Augmentation | 10 | 10 | 10 | 0 |
| SCS | 7 | 7 | 6 | 0 |
| Intrathecal Pump | 6 | 6 | 4 | 0 |
| HCPCS Drug | 5 | 5 | 5 | 0 |
| Intradiscal | 5 | 3 | 3 | 2 |
| Spine Surgery | 5 | 5 | 5 | 0 |
| Botulinum Toxin | 4 | 4 | 4 | 0 |
| Epidural | 4 | 4 | 4 | 0 |
| PNS | 4 | 4 | 4 | 0 |
| SI Joint | 4 | 4 | 4 | 0 |
| Sympathetic | 4 | 4 | 4 | 0 |
Top tracked procedures
First 15 CPT codes in the Pennsylvania Medical Assistance 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 | Sacroplasty — Unilateral | Covered |
0201T | Sacroplasty — Bilateral | Covered |
0232T | PRP — Platelet Rich Plasma Injection | Not covered |
0275T | MILD — Percutaneous Image-Guided Lumbar Decompression (DELETED 2026) | Covered |
0627T | ViaDisc / Disc Allograft — Lumbar (1st level) | Not covered |
0629T | ViaDisc / Disc Allograft — Cervical/Thoracic (1st level) | Not covered |
0779T | Percutaneous Tenotomy / Ultrasonic Debridement | Not covered |
11980 | Testopel (testosterone pellet implantation) | Covered |
20526 | Carpal Tunnel Injection | Covered |
20552 | Trigger Point Injection — 1 or 2 muscles | Covered |
20553 | Trigger Point Injection — 3+ muscles | Covered |
20610 | Major Joint Injection (without US/Fluoro) | Covered |
20611 | Major Joint Injection (with US) | Covered |
22510 | Vertebroplasty — Cervicothoracic (1st level) | Covered |
22511 | Vertebroplasty — Lumbosacral (1st level) | Covered |
See every policy for Pennsylvania Medical Assistance.
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