Medicare (CMS LCD/NCD) Facet Joint Injection / Medial Branch Block prior authorization requirements (2026)
What Medicare (CMS LCD/NCD) generally requires to approve Facet Joint Injection / Medial Branch Block (CPT 64490, 64491, 64492, 64493, 64494, 64495), for Medicare (NY) plans. Based on the cited policy, Medicare (CMS LCD/NCD) does not generally require prior authorization for Facet Joint Injection / Medial Branch Block (CPT 64490, 64491, 64492, 64493, 64494, 64495). Confirm with Medicare (CMS LCD/NCD), as this can vary by plan.
Medical-necessity criteria Medicare (CMS LCD/NCD) generally applies
Gateway criteria for ANY facet intervention (all four required): moderate-to-severe chronic, predominantly AXIAL neck or low back pain causing functional deficit on a pain/disability scale; pain >= 3 months with documented failure of noninvasive conservative care as tolerated; ABSENCE of untreated radiculopathy or neurogenic claudication (exception: radiculopathy caused by a facet synovial cyst); and no non-facet pathology on clinical assessment or imaging that could explain the pain (fracture, tumor, infection, significant deformity). DIAGNOSTIC: medial branch block is the default - an intra-articular facet injection is diagnostic only where MBB is precluded by a documented anatomic restriction. A diagnostic block must be performed with the intent that a positive result leads to RFA at the diagnosed level. A second confirmatory block requires >= 80% relief of primary (index) pain from the first, with duration consistent with the agent used, and may occur no sooner than 2 weeks after the first. THERAPEUTIC facet injections require ALL of: two prior valid diagnostic procedures EACH giving >= 80% index-pain relief; >= 50% pain relief or >= 50% ADL/functional improvement lasting >= 3 months from the prior therapeutic procedure; AND documentation of WHY the patient is not an RFA candidate (e.g. established pseudarthrosis, implanted electrical device). FACET CYST aspiration/rupture requires advanced imaging (MRI/CT/myelogram) confirming nerve-root compression or displacement by the cyst plus documented concordant symptoms; repeatable once, and only with >= 50% consistent relief for >= 3 months. NOT COVERED: any facet intervention without CT or fluoroscopic guidance (including ultrasound or MRI guidance). Moderate/deep sedation, general anesthesia and MAC are not reasonable and necessary for IA injections, MBB or cyst aspiration. Three- and four-level facet procedures are non-covered. [NEEDS CLINICAL SPOT-CHECK]
Commonly required documentation
- Baseline pain and disability scores with the same scale repeated post-procedure
- documentation excluding radiculopathy/neurogenic claudication and non-facet pathology
- 3-month conservative-care record
- for each diagnostic block the percent index-pain relief WITH dates and duration consistent with the anesthetic used
- for therapeutic injections, an explicit statement of why RFA is not appropriate.
How to submit
- Method: No prior authorization in the office or ASC setting - bill Part B with documentation on file. HOSPITAL OUTPATIENT DEPARTMENT: facet joint interventions have required CMS OPD prior authorization since 07/01/2023 - submit to the MAC before the service; standard decision is 7 calendar days for requests on or after 01/01/2025.
Sources & verification
- BindingSource — LCD: Facet Joint Interventions for Pain Management (L35936) · effective 2026-04-09.View
- BindingSource — Prior Authorization for Certain Hospital Outpatient Department (OPD) Services - facet joint interventions added 07/01/2023 (42 CFR 419.83) · effective 2023-07-01.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 2026-08-10.
Frequently asked questions
Does Medicare (CMS LCD/NCD) require prior authorization for Facet Joint Injection / Medial Branch Block?
Based on the cited policy, Medicare (CMS LCD/NCD) does not generally require prior authorization for Facet Joint Injection / Medial Branch Block (CPT 64490, 64491, 64492, 64493, 64494, 64495). Confirm with Medicare (CMS LCD/NCD), as this can vary by plan.
What does Medicare (CMS LCD/NCD) require to approve Facet Joint Injection / Medial Branch Block?
Gateway criteria for ANY facet intervention (all four required): moderate-to-severe chronic, predominantly AXIAL neck or low back pain causing functional deficit on a pain/disability scale; pain >= 3 months with documented failure of noninvasive conservative care as tolerated; ABSENCE of untreated radiculopathy or neurogenic claudication (exception: radiculopathy caused by a facet synovial cyst); … Always confirm against the current Medicare (CMS LCD/NCD) policy.
How long does a Medicare (CMS LCD/NCD) prior authorization take?
Turnaround varies by plan and submission method. Check the Medicare (CMS LCD/NCD) portal for current timeframes.
Submitting Facet Joint Injection / Medial Branch Block to Medicare (CMS LCD/NCD)?
Praxigen checks your clinical note against these criteria before you submit and drafts a policy-cited appeal if it is denied. You review and submit; nothing is sent automatically.