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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
SC
SCDOI-MRF-CPT-63030-321
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South Carolina Department of Insurance (SCDOI) & CMS TiC Payer MRF Index
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Charleston County, SC
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Filing / IDR Window: 2026-11-19
[SCDOI-MRF-CPT-63030-321] BlueCross BlueShield of South Carolina TiC MRF Rate Disparity: Interventional Pain Management & Neuromodulation ASC (CPT 63650 / 64483)
Commercial payer TiC MRF implant device pass-through audit and ERISA 29 CFR 2560.503-1 prior-authorization denial appeal cohort for Sc Interventional Pain Management & Neuromodulation centers (CPT 63650 Percutaneous Spinal Cord Stimulator Lead Implantation, CPT 64635 Lumbar Medial Branch Radiofrequency Ablation, CPT 64493 Lumbar Facet Joint Injection, and CPT 62323 Lumbar Interlaminar Epidural) across BlueCross BlueShield of South Carolina & UnitedHealthcare.
Cohort MRF 75th-Pct Value
$1,915,000
Target % of Medicare
239.0% MPFS
Statutory Authority
SC-GPCI-2026 (S.C. Code Ann. § 38-59-230)
ERISA / Timely-Filing Window
90 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 | Lumbar Laminotomy (Hemilaminectomy) with Decompression | CLAIM | 580 | $1,874.60 | $4,418.70 | $5,582.60 |
| CPT-22551 | Anterior Cervical Discectomy & Interbody Fusion (ACDF) | CLAIM | 165 | $2,718.17 | $6,407.11 | $8,094.77 |
| CPT-99214-25 | Level 4 Established Patient Outpatient E/M with Separately Identifiable Modifier 25 | CLAIM | 1,200 | $115.00 | $172.00 | $204.00 |
2. Regional Peer Specialty Groups & EIN/NPI MRF Comparables (API #11)
Southeastern Spine Institute Mount Pleasant ASCPrisma Health Patewood Outpatient CenterMUSC Health Nexton Surgery CenterLabtech Diagnostics CarolinasMidlands Orthopaedics & Neurosurgery SC