CPT 0628T · Intradiscal · Ambetter
ViaDisc — Lumbar (additional level) at Ambetter.
How Ambetter approaches CPT 0628T (ViaDisc — Lumbar (additional level)) for prior-authorization review: at last review on 2026-04-26, the policy does not cover this code with prior authorization required.
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Coverage
Not covered
Prior auth
Prior auth required
Last reviewed
2026-04-26
Policy number
Clearway-MPG-ViaDiscCriteria summary
High-level themes from the Ambetter policy of record for CPT 0628T. Verbatim policy text and per-criterion analysis are available after sign-in.
- At least 26 weeks of conservative care typically required.
- Imaging concordance documentation required.
Source: Clearway Master Payer Guidelines v2025 — ViaDisc
See the full Ambetter criteria.
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