CPT 64625 · RFA · Highmark Wholecare — PA HealthChoices
SI Joint RFA (lateral branches) at Highmark Wholecare — PA HealthChoices.
How Highmark Wholecare — PA HealthChoices approaches CPT 64625 (SI Joint RFA (lateral branches)) for prior-authorization review: at last review on 2026-05-06, the policy covers this code with prior authorization required.
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Coverage
Covered
Prior auth
Prior auth required
Last reviewed
2026-05-06
Policy number
HealthHelp IPM — SI Joint Radiofrequency AblationCriteria summary
High-level themes from the Highmark Wholecare — PA HealthChoices policy of record for CPT 64625. Verbatim policy text and per-criterion analysis are available after sign-in.
- At least 6 weeks of conservative care typically required.
- Prior Two diagnostic SI lateral-branch blocks (64451) documentation required (typically with ≥75% relief).
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