Payor
UnitedHealthcare Community Plan (Medicaid)
Rubrica tracks 94 sourced coverage rules across 94 CPT codes for UnitedHealthcare Community Plan (Medicaid) — covering interventional spine, pain management, ortho spine, and orthopedics. Plan type(s): Medicaid. National policy.
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Every Rubrica record cites a specific UnitedHealthcare Community Plan (Medicaid) 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
UnitedHealthcare Community Plan (Medicaid)'s coverage stance across procedure categories tracked in the Rubrica catalog.
| Category | Rules | Covered | Prior auth | Investigational |
|---|---|---|---|---|
| Diagnostic | 14 | 14 | 1 | 0 |
| Botulinum Toxin | 9 | 0 | 0 | 0 |
| Intradiscal | 9 | 1 | 9 | 0 |
| Peripheral Joint/Tendon | 8 | 8 | 4 | 0 |
| Epidural | 7 | 7 | 3 | 0 |
| Other Procedure | 7 | 5 | 5 | 1 |
| SCS | 7 | 7 | 7 | 0 |
| Vertebral Augmentation | 6 | 4 | 6 | 0 |
| Intrathecal Pump | 4 | 4 | 4 | 0 |
| PNS | 4 | 0 | 4 | 0 |
| Peripheral Nerve Block | 4 | 4 | 0 | 0 |
| Decompression | 3 | 0 | 3 | 0 |
Top tracked procedures
First 15 CPT codes in the UnitedHealthcare Community Plan (Medicaid) 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) | Not covered |
62330 | MILD — Percutaneous Lumbar Decompression (no image guidance) | Not covered |
62331 | MILD — Percutaneous Lumbar Decompression (with image guidance) | Not covered |
64555 | PNS — Percutaneous Lead Trial/Placement | Not covered |
64580 | PNS — Open Electrode Placement (neuromuscular) | Not covered |
64590 | PNS — Generator Insertion | Not covered |
64595 | PNS — Generator Revision/Removal | Not covered |
0627T | ViaDisc / Disc Allograft — Lumbar (1st) | Not covered |
0628T | ViaDisc — Lumbar (additional level) | Not covered |
0629T | ViaDisc — Cervical/Thoracic (1st) | Not covered |
0630T | ViaDisc — Cervical/Thoracic (add'l) | Not covered |
64628 | Intracept — Basivertebral Nerve Ablation (1st) | Not covered |
64629 | Intracept — BVN Ablation (add'l) | Not 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 |
See every policy for UnitedHealthcare Community Plan (Medicaid).
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