Medicare prior authorization · 64491
64491 — Facet Joint Interventions
Subject to the hospital outpatient department prior authorization program nationwide when furnished in a hospital outpatient department. The decision is made on Medicare’s existing coverage policy; nothing in these programs changes what is covered.
The coverage policy the reviewer applies, by contractor
CMS publishes no policy references for this program’s code list. The policies below are the ones whose own procedure-code tables list 64491 — matched by CLV analysis; the linked CMS document is authoritative. Each state’s contractor writes its own, so the policy that decides a request depends on the state.
Noridian · 16 states: AK, AS, AZ, CA, GU, HI, ID, MP, MT, ND, NV, OR, SD, UT, WA, WY
- L38801 — Facet Joint Interventions for Pain Management — Noridian · CMS version 23 · captured 2026-07-28
- L38803 — Facet Joint Interventions for Pain Management — Noridian · CMS version 17 · captured 2026-07-28
This contractor publishes more than one policy listing 64491, and the capture records the contractor rather than the jurisdiction — so which one governs depends on the jurisdiction serving the state. Run the check for your state.
National Government Services · 10 states: CT, IL, MA, ME, MN, NH, NY, RI, VT, WI
- L35936 — Facet Joint Interventions for Pain Management — NGS · CMS version 58 · captured 2026-07-28
Read the documentation requirements in the linked CMS document.
Palmetto GBA · 7 states: AL, GA, NC, SC, TN, VA, WV
- L38765 — Facet Joint Interventions for Pain Management — Palmetto GBA · CMS version 27 · captured 2026-07-28
Read the documentation requirements in the linked CMS document.
WPS · 6 states: IA, IN, KS, MI, MO, NE
- L38841 — Facet Joint Interventions for Pain Management — WPS · CMS version 20 · captured 2026-07-28
Read the documentation requirements in the linked CMS document.
CGS Administrators · 2 states: KY, OH
- L38773 — Facet Joint Interventions for Pain Management — CGS Administrators · CMS version 31 · captured 2026-07-28
Read the documentation requirements in the linked CMS document.
Hospital-OPD prior authorization program
- Where
- nationwide, hospital outpatient department only
- Decision
- 7 calendar days; 2 business days expedited
- Coverage policy
- the MAC’s LCD for the state — the check below finds it
- CMS note
- Since 2023-07-01. 64492 and 64495 removed 2024-08-05 (three- and four-level procedures are non-covered under the revised LCDs).
Check 64491 for your state, diagnosis and setting
The governing policy as it stands today, whether the diagnosis is on its list, and the documentation the policy’s own text requires — quoted, source-linked, free.
Run the check →Full lists: hospital outpatient code list
Same family: 64490 · 64493 · 64494 · 64633 · 64634 · 64635 · 64636
Sources: CMS WISeR Provider and Supplier Operational Guide v7.0 (2026-07-24), Appendix A; CMS list of OPD services requiring prior authorization (2024-08-05); CMS list of ambulatory surgical center services for prior authorization (2026-03-05) and the ASC Operational Guide (2026-03-03). Codes are shown as numbers only, as CMS lists them. CPT® is a registered trademark of the American Medical Association.