64629 CPT® code: payer coverage and prior authorization27 of 28 payer prior-auth lists that name 64629 require prior authorization or set conditions: CarePlus Health Plans, Cigna, Humana, Molina Complete Care (Virginia), Molina Healthcare of Arizona, Molina Healthcare of Iowa, Molina Healthcare of Nevada, Molina Healthcare of Ohio, Molina Healthcare of Texas, Rocky Mountain Health Plans.
64629 appears in 26 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Blue Cross & Blue Shield of Rhode Island, Blue Shield of California, Capital Blue Cross, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross, Regence, UnitedHealthcare.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Back Pain - Invasive Procedures (0016) | not covered | Oct 6, 2026 | payer document |
| Aetna | Intraoperative Neurophysiological Monitoring (0697) | not covered (range 64600-64647) | Jun 19, 2026 | payer document |
| Aetna | Intravenous Iron Therapy (0575) | listed, no stance (range 61000-64999) | Jul 1, 2026 | payer document |
| Aetna | Laser Neurolysis (0552) | listed, no stance (range 64620-64640) | Aug 3, 2026 | payer document |
| Aetna | Post-Herpetic Neuralgia (0725) | not covered (range 64600-64640) | Oct 20, 2025 | payer document |
| Aetna | Respiratory Devices: Incentive Spirometers, Vaporizers and Intermittent Positive Pressure Breathing Machines (0479) | listed, no stance (range 61000-64999) | Jul 9, 2026 | payer document |
| Aetna | Spasticity Management (0362) | covered if criteria are met (range 64600-64640) | May 26, 2026 | payer document |
| Aetna | Thermal Perfusion Probe for Monitoring Regional Cerebral Blood Flow (0703) | listed, no stance (range 61000-64999) | Nov 24, 2025 | payer document |
| Blue Cross & Blue Shield of Mississippi | Percutaneous Intradiscal Electrothermal Annuloplasty Radiofrequency Annuloplasty Biacuplasty And Intraosseous Basivertebral Nerve Ablation | unproven / investigational | payer document | |
| Blue Cross & Blue Shield of Rhode Island | Minimally Invasive Procedures for Back Pain | covered if criteria are met | Aug 19, 2026 | payer document |
| Blue Shield of California | Ablation of Peripheral Nerves to Treat Pain (7.01.154) | listed, no stance | payer document | |
| Capital Blue Cross | Intraosseous Basivertebral Nerve Ablation (MP 1.124) Procedure codes | unproven / investigational | Jun 1, 2026 | payer document |
| Health Care Service Corporation (BCBS IL, TX, OK, NM, MT) | Intraosseous Radiofrequency Nerve Ablation of the Basivertebral Nerve for the Treatment of Low Back Pain (SUR702.020) | listed, no stance | Sep 1, 2026 | payer document |
| Premera Blue Cross | Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, Biacuplasty,and Intraosseous Basivertebral Nerve Ablation (7.01.72) | listed, no stance | Jun 22, 2026 | payer document |
| Regence | Intraosseous Radiofrequency Ablation of the Basivertebral Nerve (Surgery 225) | listed, no stance | Jan 1, 2026 | payer document |
| UnitedHealthcare | Ablative Treatment for Spinal Pain (CS001.T) | listed, no stance | Mar 1, 2026 | payer document |
| UnitedHealthcare | Ablative Treatment for Spinal Pain (2026T0107II) | listed, no stance | Feb 1, 2026 | payer document |
| UnitedHealthcare | Ablative Treatment for Spinal Pain (for Kansas Only) (CS001KS.02) | listed, no stance | Apr 1, 2026 | payer document |
| UnitedHealthcare | Ablative Treatment for Spinal Pain (for Kentucky Only) (CS001KY.10) | listed, no stance | Mar 1, 2026 | payer document |
| UnitedHealthcare | Ablative Treatment for Spinal Pain (for Nebraska Only) (CS001NE.T) | listed, no stance | Mar 1, 2026 | payer document |
| UnitedHealthcare | Ablative Treatment for Spinal Pain (for New Jersey Only) (CS001NJ.Q) | listed, no stance | Mar 1, 2026 | payer document |
| UnitedHealthcare | Ablative Treatment for Spinal Pain (for New Mexico Only) (CS001NM.C) | listed, no stance | Mar 1, 2026 | payer document |
| UnitedHealthcare | Ablative Treatment for Spinal Pain (for Ohio Only) (CS001OH.D) | listed, no stance | Apr 1, 2026 | payer document |
| UnitedHealthcare | Ablative Treatment for Spinal Pain (for Pennsylvania Only) (CS001PA.Q) | listed, no stance | Apr 1, 2026 | payer document |
| UnitedHealthcare | Ablative Treatment for Spinal Pain (for Tennessee Only) (CS001TN.R) | listed, no stance | Mar 1, 2026 | payer document |
| UnitedHealthcare | Pain Management (MMP070.12) RFA of Intraosseous BVN for Spinal Pain | listed, no stance | Sep 1, 2026 | payer document |
Prior authorization required or conditional in IN, WV.
From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.