Cigna Pain Management Procedures prior authorization requirements (2026)

Medical-necessity criteria Cigna generally applies

[NEEDS CLINICAL SPOT-CHECK] Two eviCore-authored Cigna guidelines govern this code group, both Comprehensive Musculoskeletal Management Guidelines V1.0.2026, effective 2026-08-04, published 2026-04-17: CMM-201 "Facet Joint Injections/Medial Branch Blocks" (64490-64495) and CMM-208 "Ablations/Denervations of Facet Joints and Peripheral Nerves" (64633-64636). CMM-201 — INITIAL DIAGNOSTIC FACET JOINT INJECTION / MEDIAL BRANCH NERVE BLOCK, medically necessary when ALL (verbatim): "Performed to determine whether chronic cervical, thoracic, or lumbar pain is of facet joint origin"; "Presence of predominantly axial cervical, thoracic, or lumbar pain"; "Pain has persisted for at least three (3) months."; "In the past three (3) months pain has persisted despite at least four (4) weeks of conservative treatment (e.g., exercise, physical therapy, chiropractic care, or medications to include nonsteroidal anti-inflammatory drugs [NSAIDs] or analgesics)."; "Clinical findings and imaging studies suggest no other obvious cause of the cervical, thoracic, or lumbar axial pain (e.g., central spinal stenosis with neurogenic claudication/myelopathy; foraminal stenosis or disc herniation with concordant radicular pain/radiculopathy that has been treated; infection; tumor; fracture; pseudoarthrosis; pain related to spinal instrumentation)."; "The spinal motion segment(s) is(are) not posteriorly fused at the requested level(s)."; and "A facet joint radiofrequency denervation/ablation is being considered." CMM-201 — SECOND DIAGNOSTIC BLOCK, medically necessary when ALL (verbatim): "Performed to confirm the validity of the clinical response to the initial facet joint injection."; "Administered at the same level(s) as the initial diagnostic block"; "The initial diagnostic facet joint injection/medial branch nerve block resulted in a positive response (i.e., at least 80% relief of facet-mediated pain for at least the expected minimum duration of the effect of the local anesthetic used)."; and "A facet joint radiofrequency denervation/ablation is being considered." CMM-201 — LIMITS (verbatim): "only two (2) diagnostic facet joint injections/medial branch nerve blocks at the same level(s) are considered medically necessary"; "More than two (2) facet joint injections/medial branch nerve blocks at the same level and same side are considered therapeutic rather than diagnostic"; "facet joint injections/medial branch nerve blocks are considered medically necessary only from levels C2-3 to L5-S1"; "facet joint injections/medial branch nerve blocks are considered medically necessary on no more than three (3) facet joint levels (whether unilateral or bilateral) during the same session/procedure"; "no more than three (3) contiguous levels"; and "only one invasive modality or procedure performed on the same date of service is considered medically necessary." Image guidance: medically necessary "when performed with CT- or fluoroscopic-guidance." CMM-201 — THERAPEUTIC facet injections are allowed only as an alternative when RFA is contraindicated, and the guideline names the qualifying contraindications verbatim: "established spinal pseudoarthrosis at the spinal level intended for treatment" or an "implanted electrical device (i.e., cardiac pacemaker, cardiac defibrillator, dorsal column stimulator, dorsal root ganglion stimulator, peripheral neurostimulator, cranial neurostimulator, implantable programmable drug pump)", and then only after "a documented positive response with two (2) sequential diagnostic facet joint injections/medial branch nerve blocks at the same level(s)" evidenced by "at least 80% relief of facet-mediated pain for at least the expected minimum duration of the effect of the local anesthetic used." CMM-208 — FACET JOINT RADIOFREQUENCY DENERVATION/ABLATION, medically necessary when ALL (verbatim): "Performed for facet-mediated cervical, thoracic, or lumbar axial pain resulting from disease, injury, or surgery."; "Pain has persisted for at least three (3) months."; "In the past three (3) months, pain has persisted despite at least four (4) weeks of conservative treatment..."; "There has been a documented positive response with two (2) sequential diagnostic facet joint injections/medial branch nerve blocks at the same level(s)" where "Positive response is evidenced by at least 80% relief of facet-mediated pain for at least the expected minimum duration of the effect of the local anesthetic used."; "Clinical findings and imaging studies suggest no other obvious cause of the ... axial pain"; and "The spinal motion segment(s) is(are) not posteriorly fused at the requested level(s)," with an exception "for individuals with clinically suspected pseudoarthrosis at the posteriorly fused spinal motion segment(s)." CMM-208 — REPEAT ABLATION, medically necessary when ALL (verbatim): "The procedure is performed at a minimum of six (6) months following the prior denervation/ablation."; "There is documented pain relief of at least 50% which lasted for at least 12 weeks."; and clinical findings/imaging suggest no other obvious cause of the axial pain. Verbatim note: "When performing a repeat facet joint radiofrequency denervation/ablation at the same spinal level(s) as a prior successful denervation/ablation procedure, further diagnostic facet joint injections/medial branch blocks at that(those) spinal level(s) is(are) not necessary." SACROILIAC JOINT INJECTION (27096): Praxigen did NOT retrieve the Cigna/eviCore sacroiliac guideline on 2026-08-07. No criteria are asserted for 27096 on this row — verify separately before relying on it.

Commonly required documentation

• Documentation that axial pain has persisted at least 3 months and has persisted despite at least 4 weeks of conservative treatment within the past 3 months (or documented contraindication to conservative treatment)
• imaging and clinical findings excluding other obvious causes
• documentation that the motion segment is not posteriorly fused
• explicit documentation that radiofrequency denervation/ablation is being considered
• for the second block, the same level(s) and >= 80% relief of facet-mediated pain for at least the expected minimum duration of the local anesthetic
• for ablation, two sequential positive diagnostic blocks at the same level(s)
• for repeat ablation, >= 6 months since the prior ablation and documented >= 50% relief lasting >= 12 weeks. CT or fluoroscopic guidance documented.

How to submit

• Method: Precertification through eviCore by Evernorth on behalf of Cigna. eviCore provider line 1.800.918.8924.
• Portal: eviCore by Evernorth (Cigna Musculoskeletal / Interventional Pain program)

Sources & verification

• BindingSource — Cigna Medical Coverage Policies - Musculoskeletal, CMM-201: Facet Joint Injections/Medial Branch Blocks (V1.0.2026) (CMM-201) · effective 2026-08-04.View
• BindingSource — Cigna Medical Coverage Policies - Musculoskeletal, CMM-208: Ablations/Denervations of Facet Joints and Peripheral Nerves (V1.0.2026) (CMM-208) · effective 2026-08-04.View
• BindingSource — Cigna Provider Resources — solutions eviCore manages for Cigna (includes Musculoskeletal).View

Binding = the payer's own policy. Proxy = a public, evidence-based clinical guideline the payer mirrors. Portal-only = the binding criteria are confirmed in the administrator's portal. Always confirm against the payer for the member's specific plan. Last verified 2026-08-07.

Frequently asked questions

Other Cigna prior authorization requirements

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