64628 prior authorization | Blue Cross and Blue Shield of Montana

64628, Thermal destruction of intraosseous basivertebral nerve including all imaging guidance; first 2 vertebral bodies lumbar sacral, is on the Blue Cross and Blue Shield of Montana commercial prior authorization list. Not a coverage or referral decision.

Code: 64628
Description: Thermal destruction of intraosseous basivertebral nerve including all imaging guidance; first 2 vertebral bodies lumbar sacral
Source: 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 69 Original policy

Blue Cross and Blue Shield of Montana prior authorization

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