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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
OH
OHDOI-MRF-CPT-63030
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Ohio Department of Insurance (ODI) & CGS J15 MRF Index — Columbus / Cleveland MSA
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Franklin County, OH
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Filing / IDR Window: 2026-12-02
OH Commercial Payer TiC MRF & ERISA Appeal Cohort — CPT 63030 / 22551 Spine & Neurosurgery
Commercial payer TiC MRF negotiated rate audit, CMS Medicare MPFS RVU/GPCI locality repricing, and ERISA 29 CFR § 2560.503-1 / Federal No Surprises Act (45 CFR § 149.510) IDR arbitration package for Neurosurgery & Spine in OH (CPT 63030 Lumbar Discectomy & CPT 22551 Anterior Cervical Fusion (ACDF)).
Cohort MRF 75th-Pct Value
$1,920,000
Target % of Medicare
249.0% MPFS
Statutory Authority
OH-GPCI-2026-CMH (Medicare Locality 15202-00 & O.R.C. § 3901.389 18% Prompt-Pay)
ERISA / Timely-Filing Window
180 Days
1. Commercial Payer TiC MRF Allowed-Amount Benchmarks (API #02)
| CPT / DRG Code | Clinical Procedure Description | Unit | Cohort Claims | MRF 25th Pct | MRF Median (QPA) | MRF 75th Pct |
|---|---|---|---|---|---|---|
| CPT-63030 | Laminotomy (Hemilaminectomy), with Decompression of Nerve Root(s), Including Partial Facetectomy, Lumbar | CLAIM | 270 | $2,031.75 | $4,429.00 | $5,676.00 |
| CPT-22551 | Arthrodesis, Anterior Interbody, Including Disc Space Preparation, Discectomy, Osteophytectomy, Cervical Below C2 | CLAIM | 175 | $3,923.75 | $8,428.00 | $10,416.75 |
| CPT-63047 | Laminectomy, Facetectomy and Foraminotomy, Single Vertebral Segment; Lumbar | CLAIM | 225 | $2,311.25 | $4,934.25 | $6,170.50 |
| CPT-64483 | Injection(s), Anesthetic Agent and/or Steroid, Transforaminal Epidural, with Fluoroscopic Guidance; Lumbar/Sacral | CLAIM | 600 | $311.75 | $688.00 | $876.12 |
| CPT-29881 | Orthopedic & ASC: Arthroscopy, Knee, Surgical; with Meniscectomy (Medial/Lateral) & CPT 27447 Total Knee | CLAIM | 420 | $640.00 | $1,185.00 | $1,495.00 |
| CPT-45380 | Gastroenterology & Endoscopy ASC: Flexible Colonoscopy with Biopsy & CPT 43239 Upper GI EGD | CLAIM | 610 | $520.00 | $795.00 | $1,140.00 |
| CPT-66984 | Ophthalmology & Ophthalmic ASC: Extracapsular Cataract Removal with IOL Prosthesis & CPT 67028 | CLAIM | 540 | $680.00 | $985.00 | $1,390.00 |
| CPT-52356 | Urology & Lithotripsy: Cystourethroscopy with Ureteroscopy, Lithotripsy & Indwelling Stent Insertion | CLAIM | 230 | $810.00 | $1,240.00 | $1,745.00 |
| CPT-70553 | Diagnostic Radiology & Cardiology: Brain MRI w/ & w/o Contrast, CPT 74177 CT & CPT 93306 Echo | CLAIM | 480 | $410.00 | $685.00 | $995.00 |
| CPT-99285 | Emergency Medicine, Pathology & Anesthesia: Level-5 E/M, CPT 88305 Surgical Path & CPT 01402 QPA | CLAIM | 890 | $340.00 | $565.00 | $845.00 |
2. Regional Peer Specialty Groups & EIN/NPI MRF Comparables (API #11)
Mayfield Brain & SpineOH Regional Neurosurgery Associates PAOH Ambulatory Neurosurgery Center LLC