CPT 64484 · Epidural · Premera Blue Cross
TFESI — Lumbar/Sacral (add'l level) at Premera Blue Cross.
How Premera Blue Cross approaches CPT 64484 (TFESI — Lumbar/Sacral (add'l level)) for prior-authorization review: at last review on 2022-10-10, the policy covers this code with prior authorization required.
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Coverage
Covered
Prior auth
Prior auth required
Last reviewed
2022-10-10
Policy number
2.01.537Criteria summary
High-level themes from the Premera Blue Cross policy of record for CPT 64484. 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.
Source: Premera Medical Policy 2.01.537
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