Facet joint injections and medial branch blocks in the US: will Medicare or insurance pay?

What Medicare requires

Medicare’s facet joint intervention LCDs (for example Wellpoint Federal L35936, Noridian L38801 and CGS L38773) cover facet procedures when:

• you have moderate to severe neck or low back pain, mainly in the spine rather than the arm or leg, for at least 3 months, and it limits your function
• conservative care hasn’t worked, and nothing else better explains the pain
• the procedure uses fluoroscopy or CT guidance, at 1 or 2 levels per session

Two diagnostic medial branch blocks are required before radiofrequency ablation, each giving at least 80% relief of your main pain. The limit is 4 diagnostic sessions per region in 12 months.

Therapeutic facet injections or blocks (for pain relief, not diagnosis) are covered only if you’ve had two positive diagnostic blocks and there is a documented reason you can’t have radiofrequency ablation. Repeats need at least 50% relief for 3 months, up to 4 a year.

Not covered: 3 or more levels in one session, ultrasound-guided injections, routine sedation, prolotherapy, and pain such as fibromyalgia.

Hospital prior authorization

Since July 1, 2023, Original Medicare has required prior authorization for facet joint interventions done in a hospital outpatient department (CPT 64490, 64491, 64493 and 64494, plus radiofrequency codes 64633 to 64636). The program applies to hospital outpatient departments, not to doctors’ offices or surgery centers. The hospital submits the request.

What it costs with Medicare

In 2026, Medicare’s national approved amount for a lumbar medial branch block or facet injection (CPT 64493), including the doctor’s fee, ranges from about $190 to $990, depending on where it is done: usually lowest in a doctor’s office, higher in an ambulatory surgery center and highest in a hospital outpatient department. Your 20% share is about $40 to $200.

These are national figures from CMS’s 2026 payment files, not a quote. Actual amounts vary by location, extra levels add to the cost, and you pay the Part B deductible first. A Medicare Supplement (Medigap) policy or other secondary coverage may pay your 20%. Medicare Advantage plans set their own copays.

Private insurance

• Aetna covers diagnostic blocks for pain lasting more than 3 months after 6 weeks of conservative care when radiofrequency ablation is being considered; a second block needs 80% relief from the first; up to 3 levels per session.
• UnitedHealthcare covers blocks after at least 4 weeks of conservative care, counts a block as positive at 50% relief, and considers therapeutic facet injections unproven.
• Many plans need prior authorization, often through a benefit manager such as eviCore (Cigna) or Carelon (some Blue Cross plans).

Self-pay prices

Published self-pay prices we found from US providers ranged from about $350 to $1,500 for a medial branch block or facet injection. What a price includes varies a lot: some cover only the doctor’s fee, while others include the facility, imaging guidance, sedation and medicine. Prices change, so ask the provider for a written Good Faith Estimate.

How Medicare decides

Original Medicare covers these procedures under Part B when they are medically necessary. For most pain procedures there is no national rule. Instead, the regional company that processes Medicare claims in your state (a Medicare Administrative Contractor, or MAC) publishes a local coverage determination (LCD). The LCDs for each procedure are nearly identical across the country. In Illinois, Minnesota, Wisconsin, New York and New England, the contractor is Wellpoint Federal, formerly National Government Services.

Medicare Advantage plans must follow the same national and local coverage rules, but they can require prior authorization. Since January 2026, they must decide standard prior authorization requests within 7 calendar days and urgent ones within 72 hours. How coverage works in the US.

If you’re uninsured or paying yourself

Under the No Surprises Act, if you don’t have insurance or choose not to use it, you have the right to a written Good Faith Estimate when you schedule a service at least 3 business days ahead, or whenever you ask. If your final bill from a provider is at least $400 more than its estimate, you can dispute it with the federal patient-provider dispute process within 120 days of the bill date. There is a small fee.

Ask whether a cash price includes the doctor, the facility, imaging guidance, sedation and the medicine itself, because published prices differ in what they cover.

Paying with an HSA or deducting it

Medical procedures and physical therapy that treat a medical condition are generally qualified medical expenses for a health savings account (HSA) or flexible spending account (FSA). In 2026 you can put up to $4,400 (self-only) or $8,750 (family) into an HSA if you have a qualifying high-deductible plan. If you itemize, unreimbursed medical expenses above 7.5% of your adjusted gross income can be deducted.

If you are denied

• Private plans: ask for the denial and the policy it relies on in writing. You have 180 days from the denial notice to file an internal appeal; in urgent cases the plan must decide within 72 hours. If the plan still says no, you can ask for an independent external review within 4 months, and the insurer must accept the reviewer’s decision.
• Original Medicare: you have 120 days from the date on your Medicare Summary Notice to ask for a redetermination.
• Medicare Advantage: ask your plan for a reconsideration within 65 days of the denial notice.
• Your doctor’s office can often help with a peer-to-peer review or a letter of medical necessity. Your state insurance department can also help with complaints about private plans.

Frequently asked questions

Does Medicare cover medial branch blocks?

Yes, as a diagnostic test for facet joint pain before radiofrequency ablation. Medicare requires two blocks, each with at least 80% relief, before it will cover ablation.

Do facet injections need prior authorization with Medicare?

Only in hospital outpatient departments, where Original Medicare has required it since July 2023. Medicare Advantage and private plans often require it wherever the procedure is done.

This page explains how coverage usually works in the United States, using the public Medicare, insurer, government and provider sources listed above. It is general information, not medical, insurance, financial or legal advice, and it does not recommend any treatment, plan or provider. Coverage depends on your plan, your diagnosis and where you live, and rules and prices change, so confirm with your doctor, your plan or Medicare, and the provider before you decide. Protocol Archive is independent and is not affiliated with Medicare, CMS or any insurer.