CPT 64493 · Facet/MBB · Priority Partners MCO
Facet/MBB — Lumbar/Sacral (1st level) at Priority Partners MCO.
How Priority Partners MCO approaches CPT 64493 (Facet/MBB — Lumbar/Sacral (1st 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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eviCore CMM-201Criteria summary
High-level themes from the Priority Partners MCO policy of record for CPT 64493. 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: JHHC / eviCore CMM-201 — Facet Joint Injections / Medial Branch Blocks (Priority Partners)
See the full Priority Partners MCO criteria.
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