CPT 64490 · Facet/MBB · Independence Blue Cross
Facet/MBB — Cervical/Thoracic (1st level) at Independence Blue Cross.
How Independence Blue Cross approaches CPT 64490 (Facet/MBB — Cervical/Thoracic (1st level)) for prior-authorization review: at last review on 2025-06-11, the policy covers this code with prior authorization required.
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11.15.23lCriteria summary
High-level themes from the Independence Blue Cross policy of record for CPT 64490. Verbatim policy text and per-criterion analysis are available after sign-in.
- At least 6 weeks of conservative care typically required.
- Imaging concordance documentation required.
Source: Independence Blue Cross Commercial 11.15.23l — Paravertebral Facet Joint Blocks
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