CPT 64495 · Facet/MBB · UPMC for You — PA HealthChoices

Facet/MBB — Lumbar/Sacral (3rd+ level) at UPMC for You — PA HealthChoices.

How UPMC for You — PA HealthChoices approaches CPT 64495 (Facet/MBB — Lumbar/Sacral (3rd+ level)) for prior-authorization review: at last review on 2026-05-06, the policy does not cover this code with prior authorization required.

Free with practitioner sign-in — magic-link email auth, no credit card.

Coverage Not covered

Prior auth Prior auth required

Last reviewed 2026-05-06

Policy numberL34892

Criteria summary

High-level themes from the UPMC for You — PA HealthChoices policy of record for CPT 64495. Verbatim policy text and per-criterion analysis are available after sign-in.

Coverage criteria details available after sign-in.

Source: UPMC Health Plan Medical Policies + Novitas JL LCD L34892 (Facet Joint Interventions for Pain Management) — adopted via PA MA FFS floor

See the full UPMC for You — PA HealthChoices criteria.

Sign in for verbatim conservative-care language, exact imaging-concordance rules, repeat-procedure thresholds, and the denial-risk score for any specific clinical scenario.

Facet/MBB — Lumbar/Sacral (3rd+ level) at UPMC for You — PA HealthChoices.

Criteria summary

See the full UPMC for You — PA HealthChoices criteria.

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