CPT 64492 · Facet/MBB · Wellpoint Maryland
Facet/MBB — Cervical/Thoracic (3rd+ level) at Wellpoint Maryland.
How Wellpoint Maryland approaches CPT 64492 (Facet/MBB — Cervical/Thoracic (3rd+ level)) for prior-authorization review: at last review on 2026-04-27, the policy covers this code with prior authorization required.
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Carelon IPM (MSK01)Criteria summary
High-level themes from the Wellpoint Maryland policy of record for CPT 64492. 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: Carelon Clinical Appropriateness Guidelines — Interventional Pain Management
See the full Wellpoint Maryland criteria.
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