64636 prior authorization | Premera Blue Cross of Washington

64636, Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure), is on the Premera Blue Cross of Washington prior authorization list. Not a coverage or referral decision.

Code: 64636
Description: Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure)
Source: Clinical Review by Code List PBCWA, Pg 381 Original policy

Premera Blue Cross of Washington prior authorization

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