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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
CA
CADMHC-MRF-CPT-63030-SFO
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California Department of Managed Health Care (DMHC) & Noridian JE MRF Index — Bay Area MSA
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San Mateo County, CA
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Filing / IDR Window: 2026-11-20
[CADMHC-MRF-CPT-63030-SFO] Anthem Blue Cross & Aetna MRF Rate Spread, Knox-Keene Prompt-Pay & ERISA Appeal (CPT 63030 / 22551 Spine & Neurosurgery)
Commercial payer MRF negotiated rate benchmark, Noridian Medicare MAC LCD L34220 medical necessity appeal, and Knox-Keene Act (CA Health & Safety Code § 1371) 15% per annum statutory interest demand for Spine & Neurosurgery procedures (CPT 63030 Lumbar Laminotomy/Discectomy, CPT 22551 Anterior Cervical Discectomy & Fusion ACDF, and CPT 22612 Lumbar Posterolateral Arthrodesis).
Cohort MRF 75th-Pct Value
$2,480,000
Target % of Medicare
18.0% MPFS
Statutory Authority
CA-GPCI-2026-SFO (Medicare Locality 01112-07 & CA Health & Safety § 1371 15% Prompt-Pay)
ERISA / Timely-Filing Window
650 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), 1 Interspace, Lumbar | CLAIM | 185 | $1,450.00 | $3,420.00 | $4,280.00 |
| CPT-22551 | Arthrodesis, Anterior Interbody, Including Disc Space Prep & Decompression, Cervical Below C2 (ACDF) | CLAIM | 140 | $2,890.00 | $6,450.00 | $8,190.00 |
| CPT-22612 | Arthrodesis, Posterior or Posterolateral Technique, Single Interspace, Lumbar | CLAIM | 95 | $2,650.00 | $5,890.00 | $7,450.00 |
| CPT-20931 | Allograft, Structural, for Spine Surgery Only (List Separately Add-On Code) | CLAIM | 235 | $310.00 | $740.00 | $920.00 |
2. Regional Peer Specialty Groups & EIN/NPI MRF Comparables (API #11)
120 Spalding Surgery Center, Llc (NPI 1689113037)120 Spalding Partners, Llc (NPI 1326498155)Pacific Spine & Neurosurgery InstituteSilicon Valley Ambulatory Surgery CenterGolden State Orthopedic & Spine Medical GroupBay Area Minimally Invasive Surgery Center