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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] Blue Shield of California & Anthem Blue Cross TiC MRF Rate Disparity: Spine & Neurosurgery Outpatient Decompression/Fusion (CPT 63030 / 22551)
Commercial payer TiC MRF negotiated rate percentile audit and ERISA 29 CFR 2560.503-1 clinical medical-necessity appeal cohort for California Spine & Neurosurgery procedures (CPT 63030 Lumbar Laminotomy/Discectomy, CPT 22551 Anterior Cervical Discectomy & Fusion ACDF, CPT 63047 Lumbar Laminectomy, and CPT 64483 Transforaminal Epidural Injection) across Blue Cross Blue Shield of California & UnitedHealthcare.
Cohort MRF 75th-Pct Value
$1,985,000
Target % of Medicare
246.5% MPFS
Statutory Authority
CA-GPCI-2026-SFO (Medicare Locality 01112-07 & CA Health & Safety § 1371 15% 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 | 225 | $1,804.95 | $3,934.60 | $5,042.40 |
| CPT-22551 | Arthrodesis, Anterior Interbody, Including Disc Space Preparation, Discectomy, Osteophytectomy, Cervical Below C2 | CLAIM | 130 | $3,485.75 | $7,487.20 | $9,253.95 |
| CPT-63047 | Laminectomy, Facetectomy and Foraminotomy, Single Vertebral Segment; Lumbar | CLAIM | 180 | $2,053.25 | $4,383.45 | $5,481.70 |
| CPT-64483 | Injection(s), Anesthetic Agent and/or Steroid, Transforaminal Epidural, with Fluoroscopic Guidance; Lumbar/Sacral | CLAIM | 555 | $276.95 | $611.20 | $778.32 |
2. Regional Peer Specialty Groups & EIN/NPI MRF Comparables (API #11)
120 Spalding Surgery Center, Llc (NPI 1689113037)120 Spalding Partners, Llc (NPI 1326498155)Cedars-Sinai Kerlan-Jobe Surgery CenterDISC Sports & Spine Center Newport BeachSutter Sierra Surgery CenterPacific Rim Orthopedic Surgeons Medical Group