CPT 64628 · BVN ablation · Premera Blue Cross
Intracept — Basivertebral Nerve Ablation (1st level) at Premera Blue Cross.
How Premera Blue Cross approaches CPT 64628 (Intracept — Basivertebral Nerve Ablation (1st level)) for prior-authorization review: at last review on Date not on file, the policy does not cover this code with prior authorization required.
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TBDVerification pending. This record is awaiting confirmation against the latest policy document — criteria summary may not reflect the current revision.
Criteria summary
High-level themes from the Premera Blue Cross policy of record for CPT 64628. 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: Premera Medical Policy Manual — BVN policy not directly identified
See the full Premera Blue Cross criteria.
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