CPT 64555 · PNS · AmeriHealth Caritas Family (ACPA / AC Northeast / Keystone First) — PA HealthChoices
PNS — Percutaneous Lead Trial/Placement at AmeriHealth Caritas Family (ACPA / AC Northeast / Keystone First) — PA HealthChoices.
How AmeriHealth Caritas Family (ACPA / AC Northeast / Keystone First) — PA HealthChoices approaches CPT 64555 (PNS — Percutaneous Lead Trial/Placement) for prior-authorization review: at last review on 2026-05-06, the policy covers this code with prior authorization required.
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eviCore CMM-211 (PNS section)Criteria summary
High-level themes from the AmeriHealth Caritas Family (ACPA / AC Northeast / Keystone First) — PA HealthChoices policy of record for CPT 64555. Verbatim policy text and per-criterion analysis are available after sign-in.
- At least 24 weeks of conservative care typically required.
- Prior Diagnostic peripheral nerve block at target nerve documentation required (typically with ≥50% relief).
Source: eviCore CMM-211 / Joint and Spine Procedures — PNS (AC Family / Keystone First)
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