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64635

PAYER POLICY CHANGES

64635 Insurance Policy Changes

CPT 64635, in plain terms, covers Destruction of the nerve supplying one lumbar or sacral facet joint using heat or a neurolytic agent under fluoroscopic or CT guidance. Further joints use an add-on code. CPT 64635 is referenced in 8 tracked payer policy changes from Excellus BlueCross BlueShield, Capital Blue Cross, and 3 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 64635 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Official descriptor: CPT 64635 on AAPC

Excellus BlueCross BlueShield · Effective Jan 1, 2027Medium impact
Interventional Pain Management for Managed Medicaid (MMC), Health and Recovery Plan (HARP), Child Health Plus (CHP), and Essential Plan (EP) Members - (Effective Date - 2027-01-01) 7.01.122
Excellus BlueCross BlueShield's new medical policy 7.01.122 takes effect January 1, 2027 and covers interventional pain management for Managed Medicaid (MMC), Health and Recovery Plan (HARP), Child Health Plus (CHP), and Essential Plan (EP) members. It sets criteria for epidural steroid injections, selective nerve root blocks, facet joint injections and medial branch blocks, radiofrequency neurolysis, and sacroiliac joint injections. Each procedure is considered medically appropriate only when all of its listed criteria are met, and is considered not medically necessary when any listed contraindication applies.
Capital Blue Cross · Effective Mar 1, 2026High impact
AB2026-02-003 Medical policies
Capital Blue Cross updated its medical policies with an effective date of March 1, 2026 unless otherwise indicated, and it delegated the medical specialty injectable policies to Prime Medical Pharmacy Solutions, which is making them more medication-specific for Commercial members with changed prior authorization periods for some drugs. Blenrep is a new policy, HCPCS code J9999 now requires prior authorization for it, and numerous injectables, including Botox, Opdivo SQ, Trastuzumab IV and Ocrevus IV, have revised policies effective 4/1/2026. Commercial knee brace codes L1834, L1840 and L1846 no longer require prior authorization because they are investigational, code 0707T now requires prior authorization under the Experimental and Investigational Procedures policy, and several Medicare Advantage medical policies were retired effective March 1, 2026.
Excellus BlueCross BlueShield · Effective Oct 15, 2026Medium impact
Radiofrequency Facet and Sacroiliac Joint Ablation/ Denervation - (Effective Date - 2026-10-15) 7.01.42
Facet joint radiofrequency denervation is medically appropriate for facet-mediated cervical, thoracic or lumbar axial pain that has persisted at least three months despite at least four weeks of conservative treatment in the past three months, after two sequential diagnostic facet joint injections or medial branch blocks at the same level each gave at least 80% relief. Repeat denervation requires at least 50% pain relief lasting at least 12 weeks after the prior procedure and at least six months after it, and it is considered not medically necessary when more than two denervations occur at the same level in a rolling 12-month period. Pulsed, endoscopic, cryoablation, chemical, laser and cooled radiofrequency techniques are considered investigational, as are radiofrequency ablation of the sacroiliac joint nerves and intraosseous basivertebral nerve ablation for vertebrogenic back pain.
Sentara Health Plans · Effective Nov 1, 2025Medium impact
Authorization Updates - Effective November 1, 2025
Sentara Health Plans' authorization updates effective November 1, 2025 archived the Apixaban (Eliquis) Drug Level policy (Medical 303), Corneal Procedures (Surgical 55) and Percutaneous Transluminal Coronary Lithotripsy for all lines of business, and archived Injectable Hormone Pellets (Medical 157) for Commercial and Medicaid. The same date archived the Substernal Implantable Cardioverter-Defibrillator (Surgical 130) and Thermal Intradiscal Procedures (Surgical 79) policies for Commercial and Medicaid, renamed the subcutaneous defibrillator policy Subcutaneous and Substernal Implantable Cardioverter-Defibrillator, and set authorization required (Y) for codes 28446 and 29891 and for J8597 (Commercial). Criteria were also updated for Commercial and Medicaid for compression stockings, leadless cardiac pacemakers, skin and tissue substitutes, and spinal and other pain management procedures.
Aetna · Identified Oct 19, 2026Medium impact
Transforaminal Epidural Injections (CPB 0722, reviewed 2026-10-14)
Aetna's Clinical Policy Bulletin 0722 covers transforaminal epidural steroid injections (TFESIs) performed with imaging guidance (fluoroscopy or CT) when the criteria for diagnostic or therapeutic use are met. Diagnostic selective TFESIs are considered medically necessary for identifying the etiology of pain in persons with symptoms suggestive of chronic radiculopathy when the diagnosis remains uncertain after standard evaluation. An initial therapeutic TFESI is considered medically necessary for radiculopathy when non-invasive measures such as physical therapy and non-narcotic analgesics have failed or become intolerant, and additional therapeutic TFESIs are considered medically necessary when the initial injection produced at least two specified outcomes for at least 2 weeks. Aetna considers TFESIs at more than two contiguous vertebral levels or more than four TFESIs in a single session not medically necessary.
Aetna · Identified Aug 17, 2026Medium impact
Neurogenic Bladder: Selected Treatments (CPB 0852, reviewed 2025-12-23)
Aetna's Clinical Policy Bulletin 0852 on neurogenic bladder, last reviewed 12/23/2025, considers enterocystoplasty (augmentation cystoplasty) or urinary diversion surgery medically necessary when conservative treatments, including anticholinergic medications and urinary catheters, have failed or are contraindicated. The policy considers a long list of other treatments experimental, investigational or unproven for neurogenic bladder, including acupuncture, beta-agonists such as mirabegron, biofeedback, peripheral neuromodulation (pudendal, sacral and tibial nerve stimulation), TENS, transcranial magnetic stimulation, transurethral electrical stimulation, and intravesical gentamicin or neomycin-polymyxin. CPT codes 51960 (enterocystoplasty) and 50825 (continent diversion) are covered if selection criteria are met.
Aetna · Identified Aug 16, 2026Medium impact
Transforaminal Epidural Injections (CPB 0722, reviewed 2025-10-20)
Aetna considers diagnostic selective transforaminal epidural steroid injections (TFESIs) with imaging guidance medically necessary for chronic radiculopathy when the diagnosis remains uncertain after standard evaluation, and considers an initial therapeutic TFESI medically necessary when physical therapy and non-narcotic analgesics have failed or become intolerant and the radicular pain is consistent with radiologic findings. Additional therapeutic TFESIs are medically necessary when the initial injection produced at least two of the following for at least 2 weeks: 50% or greater pain relief, increased level of function or physical activity, or reduced pain medication use and/or additional medical care such as physical therapy or chiropractic care. A maximum of twelve TFESIs per spinal region is considered medically necessary, administered during a maximum of three sessions for an episode of pain lasting six months, and TFESI sessions more frequent than every two weeks are considered not medically necessary.
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026Medium impact
Facet Blocks for Treatment of Back Pain
Which updated the sources, removed ICD-9 codes from the code reference and left the policy statements unchanged. Facet blocks for back pain are medically necessary when facet joint pain is suspected in patients with back pain without a strong radicular component or associated neurologic deficit. Two sessions per level per calendar year, with a maximum of three facet blocks per session using local anesthetic, corticosteroid or phenol, are considered medically necessary, and thermal non-pulsed radiofrequency destruction is not medically necessary except as a last resort.

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REFERENCE DATA

Payers with rules21

Payers requiring prior auth21

Aetna · Effective November 1, 2026
Prior authorization required
Participating provider precertification list for Aetna
Anthem BCBS · Effective November 1, 2026
Prior authorization required
Anthem Local PPO Precertification/Prior Authorization List (California | Anthem Blue Cross | Commercial)
Fidelis Care · Effective November 1, 2026
Prior authorization required in some cases
Fidelis Care Metal-Level Products authorization grid

FREQUENTLY ASKED QUESTIONS

Does Aetna require prior authorization for 64635?

Aetna lists 64635 on Participating provider precertification list for Aetna for commercial plans (list dated November 1, 2026). Verify with the payer before scheduling.

Does Ambetter require prior authorization for 64635?

Ambetter lists 64635 on Ambetter from Arizona Complete Health CMS-0057-F prior authorization requirements for exchange plans (list dated December 31, 2025). Verify with the payer before scheduling.

Does Anthem BCBS require prior authorization for 64635?

Anthem BCBS lists 64635 on Anthem Local PPO Precertification/Prior Authorization List (California | Anthem Blue Cross | Commercial) for commercial plans (list dated November 1, 2026). Verify with the payer before scheduling.

Does Arizona Complete Health require prior authorization for 64635?

Arizona Complete Health lists 64635 on Arizona Complete Health CMS-0057-F prior authorization requirements for medicaid managed plans (list dated December 31, 2025). Verify with the payer before scheduling.

Does BCBS Arizona require prior authorization for 64635?

BCBS Arizona lists 64635 on AZ Blue Standard Prior Authorization Requirements Code List (Updated 10/01/2026) for commercial plans (list dated October 1, 2026). Verify with the payer before scheduling.

What insurance policy changes affect CPT 64635?

There are 8 tracked policy changes affecting CPT 64635, including updates from Excellus BlueCross BlueShield, Capital Blue Cross, Sentara Health Plans. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for CPT 64635?

Payers that have issued tracked updates for CPT 64635 include: Excellus BlueCross BlueShield, Capital Blue Cross, Sentara Health Plans, Aetna, Blue Cross & Blue Shield of Mississippi.

How do I get notified when CPT 64635 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to CPT 64635. You will get an email when new policy changes reference this code: daily or weekly, your choice, on every plan.

Why do payers change policies for CPT 64635?

Payers revise policies for individual billing codes to align with updated clinical guidelines, CMS rule changes, fraud and abuse prevention measures, or network cost-management goals. Changes can affect medical necessity criteria, place-of-service restrictions, bundling rules, or whether a code requires prior authorization.

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Prior authorization lists, coverage criteria, NCCI edits and Medicare coverage articles for 64635 in one place.

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All billing codes J3590 C9399 J3490 99215 99213 99202

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Interventional Pain Management for Managed Medicaid (MMC), Health and Recovery Plan (HARP), Child Health Plus (CHP), and Essential Plan (EP) Members - (Effective Date - 2027-01-01) 7.01.122

AB2026-02-003 Medical policies

Radiofrequency Facet and Sacroiliac Joint Ablation/ Denervation - (Effective Date - 2026-10-15) 7.01.42

Authorization Updates - Effective November 1, 2025

Transforaminal Epidural Injections (CPB 0722, reviewed 2026-10-14)

Neurogenic Bladder: Selected Treatments (CPB 0852, reviewed 2025-12-23)

Transforaminal Epidural Injections (CPB 0722, reviewed 2025-10-20)

Facet Blocks for Treatment of Back Pain

Prior authorization required