0628T prior authorization | Anthem Blue Cross and Blue Shield New Hampshire

0628T, Percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; each additional level (List separately in addition to code for primary procedure), is on the Anthem Blue Cross and Blue Shield New Hampshire prior authorization list. Not a coverage or referral decision.

Code: 0628T
Description: Percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; each additional level (List separately in addition to code for primary procedure)
Source: New Hampshire Precertification List, Pg 65 Original policy

Anthem Blue Cross and Blue Shield New Hampshire prior authorization

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