Medicare (CMS LCD/NCD) Pain Management Procedures prior authorization requirements (2026)
What Medicare (CMS LCD/NCD) generally requires to approve Pain Management Procedures (CPT 27096, 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495, 64510, 64520, 64633, 64634, 64635, 64636, 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 0627T, 0628T, 0629T, 0630T, G0259, G0260), for Medicare plans. Yes. Medicare (CMS LCD/NCD) generally requires prior authorization for Pain Management Procedures (CPT 27096, 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495, 64510, 64520, 64633, 64634, 64635, 64636, 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 0627T, 0628T, 0629T, 0630T, G0259, G0260).
Medical-necessity criteria Medicare (CMS LCD/NCD) generally applies
Mixed-scope code group - which Part B review program applies depends on the code and setting. (1) Facet joint interventions (64490-64495, 64633-64636): on the CMS hospital-OPD prior-authorization list (42 CFR 419.83, since July 2023) - the HOSPITAL obtains prior authorization for HOPD claims; office claims have no PA but LCD frequency/level limits apply. (2) Epidural steroid injections (62320-62327, 64479-64484): a WISeR model category - in NJ/OH/OK/TX/AZ/WA (from Jan 2026) submit prior authorization or the claim faces 100% pre-payment medical review (see the Epidural Steroid Injection procedure entry for detail). (3) Other codes in this group: no Part B PA; medical necessity per the applicable MAC LCD. Marked PA-required as the conservative default because the highest-volume members of this group trigger a review program in at least one common setting. [NEEDS CLINICAL SPOT-CHECK]
Commonly required documentation
- Clinical documentation per the applicable LCD: diagnosis, conservative-care history, imaging correlation, response to prior injections, and (facet) documented levels/laterality.
How to submit
- Method: HOPD facet claims: hospital submits PA to the MAC. NJ (Novitas JL) ESI claims: submit WISeR prior authorization or accept 100% pre-payment review. Other office claims: no PA to submit.
Sources & verification
Sources: CMS OPD prior-authorization program page (42 CFR 419.83; facet joint interventions added July 2023); CMS WISeR model page (cms.gov/priorities/innovation/innovation-models/wiser), both verified 2026-07-09. Last verified 2026-07-09.
Frequently asked questions
Does Medicare (CMS LCD/NCD) require prior authorization for Pain Management Procedures?
Yes. Medicare (CMS LCD/NCD) generally requires prior authorization for Pain Management Procedures (CPT 27096, 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495, 64510, 64520, 64633, 64634, 64635, 64636, 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 0627T, 0628T, 0629T, 0630T, G0259, G0260).
What does Medicare (CMS LCD/NCD) require to approve Pain Management Procedures?
Mixed-scope code group - which Part B review program applies depends on the code and setting. (1) Facet joint interventions (64490-64495, 64633-64636): on the CMS hospital-OPD prior-authorization list (42 CFR 419.83, since July 2023) - the HOSPITAL obtains prior authorization for HOPD claims; office claims have no PA but LCD frequency/level limits apply. (2) Epidural steroid injections (62320-6232… 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 Pain Management Procedures 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.