Payor
UPMC for You — PA HealthChoices
Rubrica tracks 101 sourced coverage rules across 101 CPT codes for UPMC for You — 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 UPMC for You — 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
UPMC for You — PA HealthChoices's coverage stance across procedure categories tracked in the Rubrica catalog.
| Category | Rules | Covered | Prior auth | Investigational |
|---|---|---|---|---|
| Diagnostic | 14 | 14 | 14 | 0 |
| Intradiscal | 8 | 4 | 8 | 4 |
| Vertebral Augmentation | 8 | 6 | 8 | 2 |
| SCS | 7 | 7 | 7 | 0 |
| Epidural | 6 | 6 | 6 | 0 |
| Facet/MBB | 6 | 4 | 6 | 0 |
| Intrathecal Pump | 6 | 6 | 6 | 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 UPMC for You — PA HealthChoices catalog. Sign in for verbatim criteria, source links, and the rest of the catalog.
| CPT | Procedure | Coverage |
|---|---|---|
0200T | Sacroplasty — Unilateral | Not covered |
0201T | Sacroplasty — Bilateral | Not covered |
0232T | PRP — Platelet Rich Plasma Injection | Not covered |
0275T | MILD — Percutaneous Image-Guided Lumbar Decompression (DELETED 2026) | Not covered |
0627T | ViaDisc / Disc Allograft — Lumbar (1st level) | Not covered |
0628T | ViaDisc — Lumbar (additional level) | Not covered |
0629T | ViaDisc / Disc Allograft — Cervical/Thoracic (1st level) | Not covered |
0630T | ViaDisc — Cervical/Thoracic (add'l) | 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 |
22512 | Vertebroplasty — Each Additional Level | Covered |
22513 | Kyphoplasty — Thoracic (1st level) | Covered |
22514 | Kyphoplasty — Lumbar (1st level) | Covered |
22515 | Kyphoplasty — Each Additional Level | Covered |
22867 | Vertiflex — Interspinous Process Decompression (1st level) | Covered |
22868 | Vertiflex — Interspinous (add'l level) | Covered |
22869 | Vertiflex — Interspinous (1st level, no decompression) | Not covered |
22870 | MinuteMan/Inspan — Interspinous Fixation (add'l) | Not covered |
See every policy for UPMC for You — PA HealthChoices.
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