64628 prior authorization | Blue Cross Blue Shield Oklahoma

64628, Thermal destruction of intraosseous basivertebral nerve including all imaging guidance; first 2 vertebral bodies lumbar or sacral, is on the Blue Cross Blue Shield Oklahoma 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 or sacral
Source: 2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 240 Original policy

Blue Cross Blue Shield Oklahoma prior authorization

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