CPT 64635 · RFA · AmeriHealth Caritas Family (ACPA / AC Northeast / Keystone First) — PA HealthChoices
RFA — Lumbar/Sacral Facet (1st level) at AmeriHealth Caritas Family (ACPA / AC Northeast / Keystone First) — PA HealthChoices.
How AmeriHealth Caritas Family (ACPA / AC Northeast / Keystone First) — PA HealthChoices approaches CPT 64635 (RFA — Lumbar/Sacral Facet (1st level)) for prior-authorization review: at last review on 2026-05-06, the policy covers this code with prior authorization required.
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eviCore CMM-208Criteria summary
High-level themes from the AmeriHealth Caritas Family (ACPA / AC Northeast / Keystone First) — PA HealthChoices policy of record for CPT 64635. 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: eviCore CMM-208 — Facet Joint Ablation (AC Family / Keystone First)
See the full AmeriHealth Caritas Family (ACPA / AC Northeast / Keystone First) — PA HealthChoices criteria.
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