CPT 64628 · Intradiscal · Wellpoint Maryland
Intracept — Basivertebral Nerve Ablation (1st level) at Wellpoint Maryland.
How Wellpoint Maryland approaches CPT 64628 (Intracept — Basivertebral Nerve Ablation (1st level)) for prior-authorization review: at last review on 2026-04-27, the policy covers this code with prior authorization required.
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SURG.00052Criteria summary
High-level themes from the Wellpoint Maryland 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: Anthem Medical Policy SURG.00052 — Percutaneous Vertebral Disc and Vertebral Endplate Procedures
See the full Wellpoint Maryland criteria.
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