CPT 64625 · SI Joint
SI Joint RFA (lateral branches)
Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (fluoroscopy or CT).
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Rubrica tracks payor coverage for CPT 64625 (SI Joint RFA (lateral branches)) across 76 payors — every Medicare MAC, the major commercial plans, the BCBS family, all 50-state Medicaid programs, and selected workers' comp and auto/PIP carriers. Aggregate coverage patterns are shown below; full payor-specific criteria, source citations, and last-reviewed dates are available to signed-in practitioners.
Top payors covering CPT 64625
Sample of 12 payors with coverage for this code. Sign in for the complete payor list, verbatim criteria, denial-risk score, and source citations for each.
| Payor | Coverage | Prior auth |
|---|---|---|
| Aetna | Covered | Prior auth |
| Aetna Better Health of Florida | Covered | No PA |
| Aetna Better Health of Maryland | Covered | No PA |
| Aetna Better Health of New Jersey | Covered | No PA |
| Aetna Medicare Advantage | Covered | Prior auth |
| Alabama Medicaid | Covered | Prior auth |
| Alabama Medicaid (FFS) | Covered | Prior auth |
| Allstate Auto / PIP | Covered | Prior auth |
| AmTrust Financial WC | Covered | Prior auth |
| AmeriHealth Caritas Family (ACPA / AC Northeast / Keystone First) — PA HealthChoices | Covered | No PA |
| Anthem BCBS | Covered | Prior auth |
| California Medicaid (Medi-Cal) | Covered | Prior auth |
Coverage themes for CPT 64625
Common patterns across the 76 payors we track. Specific criteria per payor are available after sign-in.
Most payors require ≥6 weeks of conservative care before approving 64625.
6 of 76 payors require imaging concordance documentation.
Of the 76 payors with coverage records for CPT 64625, 45 require prior authorization, 16 cover without prior authorization, and 14 flag the procedure as investigational or experimental under current criteria.
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