64495 prior authorization | Blue Cross and Blue Shield of Montana

64495, Injection(S) Diagnostic Or Therapeutic Agent Paravertebral Facet (Zygapophyseal) Joint (Or Nerves Innervating That Joint) With Image Guidance (Fluoroscopy Or Ct) Lumbar Or Sacral; Third And Any Additional Level(S) (List Separately In Addition To Code For Primary Procedure), is on the Blue Cross and Blue Shield of Montana commercial prior authorization list. Not a coverage or referral decision.

Code: 64495
Description: Injection(S) Diagnostic Or Therapeutic Agent Paravertebral Facet (Zygapophyseal) Joint (Or Nerves Innervating That Joint) With Image Guidance (Fluoroscopy Or Ct) Lumbar Or Sacral; Third And Any Additional Level(S) (List Separately In Addition To Code For Primary Procedure)
Source: 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 67 Original policy

Blue Cross and Blue Shield of Montana prior authorization

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