CPT 64625 · SI Joint · Sunshine Health (Centene) — Florida Medicaid
SI Joint RFA (lateral branches) at Sunshine Health (Centene) — Florida Medicaid.
How Sunshine Health (Centene) — Florida Medicaid 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
CP.MP.166Criteria summary
High-level themes from the Sunshine Health (Centene) — Florida Medicaid 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.
- Imaging concordance documentation required.
- Prior Diagnostic SI joint or lateral branch block under fluoroscopy documentation required (typically with ≥75% relief).
See the full Sunshine Health (Centene) — Florida Medicaid criteria.
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