CPT 64624 · RFA · Health Partners Plans / Jefferson Health Plans — PA HealthChoices
Genicular Nerve RFA at Health Partners Plans / Jefferson Health Plans — PA HealthChoices.
How Health Partners Plans / Jefferson Health Plans — 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 Genicular RFACriteria summary
High-level themes from the Health Partners Plans / Jefferson Health Plans — 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 Diagnostic genicular nerve block(s) (64454) documentation required (typically with ≥80% relief).
See the full Health Partners Plans / Jefferson Health Plans — PA HealthChoices criteria.
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