CPT 64636 · RFA · UnitedHealthcare Community Plan of Pennsylvania
RFA — Lumbar/Sacral Facet (add'l level) at UnitedHealthcare Community Plan of Pennsylvania.
How UnitedHealthcare Community Plan of Pennsylvania approaches CPT 64636 (RFA — Lumbar/Sacral Facet (add'l 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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2026T0107IICriteria summary
High-level themes from the UnitedHealthcare Community Plan of Pennsylvania policy of record for CPT 64636. Verbatim policy text and per-criterion analysis are available after sign-in.
- At least 4 weeks of conservative care typically required.
- Imaging concordance documentation required.
- Prior Diagnostic MBBs (CPT 64493 series) documentation required (typically with ≥50% relief).
Source: UHC Community Plan of Pennsylvania — adopts UHC Commercial — Ablative Treatment for Spinal Pain
See the full UnitedHealthcare Community Plan of Pennsylvania criteria.
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