CPT 64490 · RFA · California Medicaid (Medi-Cal)
Facet/MBB — Cervical/Thoracic (1st level) at California Medicaid (Medi-Cal).
How California Medicaid (Medi-Cal) approaches CPT 64490 (Facet/MBB — Cervical/Thoracic (1st level)) for prior-authorization review: at last review on 2026-05-06, the policy covers this code with prior authorization required.
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Criteria summary
High-level themes from the California Medicaid (Medi-Cal) policy of record for CPT 64490. Verbatim policy text and per-criterion analysis are available after sign-in.
- At least 8 weeks of conservative care typically required.
- Prior Lumbar medial branch block documentation required (typically with ≥80% relief).
Source: California Medicaid (Medi-Cal) Coverage for Radiofrequency Ablation
See the full California Medicaid (Medi-Cal) criteria.
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