CPT G0260 · SI Joint · AmeriHealth Caritas Family (ACPA / AC Northeast / Keystone First) — PA HealthChoices
SI Joint Injection (Medicare ASC HCPCS) at AmeriHealth Caritas Family (ACPA / AC Northeast / Keystone First) — PA HealthChoices.
How AmeriHealth Caritas Family (ACPA / AC Northeast / Keystone First) — PA HealthChoices approaches CPT G0260 (SI Joint Injection (Medicare ASC HCPCS)) 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-203Criteria summary
High-level themes from the AmeriHealth Caritas Family (ACPA / AC Northeast / Keystone First) — PA HealthChoices policy of record for CPT G0260. 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.
Source: eviCore CMM-203 — Sacroiliac Joint Injection (AC Family / Keystone First)
See the full AmeriHealth Caritas Family (ACPA / AC Northeast / Keystone First) — PA HealthChoices criteria.
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