August 15, 2024
Changes to Prior Authorization for Facet Joint Interventions
According to the revised Local Coverage Determination (LCD), Facet Joint Interventions for Pain Management (L38773)
, three or four-level procedures are not medically necessary and, therefore, are non-covered. (See #7 under Limitations.)
As a result, CMS:
- Determined that a prior authorization request for these procedures is unnecessary since the decision will always be non-affirmative.
- Removed CPT codes 64492 and 64495 from the list of codes that require prior authorization as a condition of payment.
Updates to the following resources reflect this change:
- CMS Final List of Outpatient Department Services That Require Prior Authorization

- CMS Prior Authorization for Certain Hospital Outpatient Department (OPD) Services | Timeline & Updates
– Update 08/05/2024 - CGS Prior Authorization OPD: Facet Joint Interventions
Request Form - CGS Facet Joint Interventions Checklist Tool

- CGS Prior Authorization Decision Tree

