Payor
Wellpoint Maryland
Rubrica tracks 101 sourced coverage rules across 101 CPT codes for Wellpoint Maryland — covering interventional spine, pain management, ortho spine, and orthopedics. Plan type(s): Medicaid. 1-state regional policy (sample: md).
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Every Rubrica record cites a specific Wellpoint Maryland 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
Wellpoint Maryland's coverage stance across procedure categories tracked in the Rubrica catalog.
| Category | Rules | Covered | Prior auth | Investigational |
|---|---|---|---|---|
| Diagnostic | 14 | 14 | 3 | 0 |
| Intradiscal | 8 | 2 | 8 | 6 |
| Vertebral Augmentation | 8 | 6 | 8 | 2 |
| SCS | 7 | 7 | 4 | 0 |
| Epidural | 6 | 6 | 6 | 0 |
| Facet/MBB | 6 | 6 | 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 | 0 | 4 | 4 |
| PNS | 4 | 0 | 4 | 4 |
Top tracked procedures
First 15 CPT codes in the Wellpoint Maryland catalog. Sign in for verbatim criteria, source links, and the rest of the catalog.
| CPT | Procedure | Coverage |
|---|---|---|
64612 | Botox — Hemifacial Chemodenervation | Covered |
64615 | Botox — Chronic Migraine Chemodenervation | Covered |
64646 | Botox — Trunk/Axial Chemodenervation (1–5 muscles) | Covered |
64647 | Botox — Trunk/Axial Chemodenervation (6+ muscles) | Covered |
0275T | MILD — Percutaneous Image-Guided Lumbar Decompression (deleted CPT, retained for legacy DOS) | Not covered |
62330 | MILD — Percutaneous Image-Guided Lumbar Decompression (cervical/thoracic; 2026 replacement code, intralaminar approach) | Not covered |
62331 | MILD — Percutaneous Image-Guided Lumbar Decompression (lumbar; 2026 replacement for 0275T) | Not covered |
62290 | Discography — Lumbar | Covered |
62291 | Discography — Cervical/Thoracic | Covered |
72295 | Discography — Radiologic Supervision | Covered |
76882 | Ultrasound — Limited Nonvascular Extremity | Covered |
76942 | Ultrasound Guidance for Needle Placement | Covered |
77003 | Fluoroscopic Guidance (spine/joint) | Covered |
95885 | EMG — Limited Needle Study with NCS | Covered |
95886 | EMG — Complete Needle Study with NCS | Covered |
95908 | Nerve Conduction — 3–4 studies | Covered |
95909 | Nerve Conduction — 5–6 studies | Covered |
95910 | Nerve Conduction — 7–8 studies | Covered |
95911 | Nerve Conduction — 9–10 studies | Covered |
95912 | Nerve Conduction — 11–12 studies | Covered |
95913 | Nerve Conduction — 13+ studies | Covered |
62321 | Interlaminar Cervical/Thoracic Epidural Steroid Injection | Covered |
62323 | Interlaminar Lumbar/Sacral Epidural Steroid Injection | Covered |
64479 | Transforaminal Cervical/Thoracic Epidural Steroid Injection (1st level) | Covered |
64480 | Transforaminal Cervical/Thoracic ESI (additional level) | Covered |
See every policy for Wellpoint Maryland.
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