CPT 64493 · Facet/MBB · Medicare (Palmetto GBA MAC)
Facet/MBB — Lumbar/Sacral (1st level) at Medicare (Palmetto GBA MAC).
How Medicare (Palmetto GBA MAC) approaches CPT 64493 (Facet/MBB — Lumbar/Sacral (1st level)) for prior-authorization review: at last review on 2026-04-15, the policy covers this code with prior authorization required.
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L38765Criteria summary
High-level themes from the Medicare (Palmetto GBA MAC) policy of record for CPT 64493. Verbatim policy text and per-criterion analysis are available after sign-in.
- At least 12 weeks of conservative care typically required.
- Imaging concordance documentation required.
Source: LCD - Facet Joint Interventions for Pain Management (L38765)
See the full Medicare (Palmetto GBA MAC) criteria.
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