CPT 64624 · RFA · Wellpoint of New Jersey — NJ Medicaid
Genicular Nerve RFA at Wellpoint of New Jersey — NJ Medicaid.
How Wellpoint of New Jersey — NJ Medicaid 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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Criteria summary
High-level themes from the Wellpoint of New Jersey — NJ Medicaid 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) with ≥80% relief of index pain documentation required (typically with ≥80% relief).
Source: Wellpoint NJ UM — genicular RFA (Carelon-aligned framework; no dedicated Carelon guideline)
See the full Wellpoint of New Jersey — NJ Medicaid criteria.
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