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Issue Number - Name
0095-Facet Injections
Review Type
Claim Type
Outpatient Hospital, Ambulatory Surgery Center
Region and State
RAC 1-4
All States
Date Approved


Facet Joint Injections are reasonable and necessary for chronic pain (persistent pain for three (3) months or greater) suspected to originate from the facet joint. Medical documentation will be reviewed to determine that services were medically reasonable and necessary.

Affected Code(s)

  • 64490-64495, 64633-64636, 0213T-0218T, G0260

Applicable Policy References

  • Novitas Solutions LCD, L34892, Effective Date 10/01/2015
  • Novitas Solutions LCD, L34974, Effective Date 10/01/2015
  • Noridian Healthcare LCD, L34992, Retired 11/02/2016
  • Noridian Healthcare LCD, L34993, Effective Date 10/01/2015
  • Noridian Healthcare LCD, L34995, Effective Date 10/01/2015
  • Noridian Healthcare LCD L35178, Retired 11/2/16
  • CMS Pub. 100-20, One-Time Notification, Transmittal 526
  • Current Procedural Terminology Manual, Appendix A Modifiers, 50 Bilateral Procedures
  • Current Procedural Terminology Manual, Appendix A Modifiers, 59 Distinct Procedural Service
  • Current Procedural Terminology Manual, Appendix D Summary of CPT Add-on Codes