CPT 64634 · RFA · Priority Partners MCO
RFA — Cervical/Thoracic Facet (add'l level) at Priority Partners MCO.
How Priority Partners MCO approaches CPT 64634 (RFA — Cervical/Thoracic Facet (add'l level)) for prior-authorization review: at last review on 2026-04-27, the policy covers this code with prior authorization required.
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eviCore CMM-208Criteria summary
High-level themes from the Priority Partners MCO policy of record for CPT 64634. 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 Two diagnostic facet/medial branch blocks at target level documentation required (typically with ≥80% relief).
Source: JHHC / eviCore CMM-208 — Facet Joint Ablation (Priority Partners)
See the full Priority Partners MCO criteria.
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