CPT 64624 · RFA · AmeriHealth Caritas Family (ACPA / AC Northeast / Keystone First) — PA HealthChoices
Genicular Nerve RFA at AmeriHealth Caritas Family (ACPA / AC Northeast / Keystone First) — PA HealthChoices.
How AmeriHealth Caritas Family (ACPA / AC Northeast / Keystone First) — PA HealthChoices approaches CPT 64624 (Genicular Nerve RFA) 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-208Criteria summary
High-level themes from the AmeriHealth Caritas Family (ACPA / AC Northeast / Keystone First) — PA HealthChoices policy of record for CPT 64624. Verbatim policy text and per-criterion analysis are available after sign-in.
- At least 12 weeks of conservative care typically required.
- Imaging concordance documentation required.
- Prior Two diagnostic genicular nerve blocks at target knee documentation required (typically with ≥50% relief).
Source: eviCore CMM-208 — Genicular Nerve Ablation (AC Family / Keystone First)
See the full AmeriHealth Caritas Family (ACPA / AC Northeast / Keystone First) — PA HealthChoices criteria.
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