CPT 64625 · SI Joint · Maryland Physicians Care
SI Joint RFA (lateral branches) at Maryland Physicians Care.
How Maryland Physicians Care 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.
Free with practitioner sign-in — magic-link email auth, no credit card.
NIA IPM Guidelines (2024)Criteria summary
High-level themes from the Maryland Physicians Care policy of record for CPT 64625. 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 SI joint lateral branch blocks (64451) or intra-articular SIJ blocks (27096) documentation required (typically with ≥75% relief).
Source: MPC / Evolent (NIA) IPM Guidelines — Sacroiliac Joint Procedures (RFA section)
See the full Maryland Physicians Care criteria.
Sign in for verbatim conservative-care language, exact imaging-concordance rules, repeat-procedure thresholds, and the denial-risk score for any specific clinical scenario.
Sign in — free for practitioners →