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CGS PAR 573: OPD Facet Joint Prior Authorization

Kentucky and Ohio hospital outpatient departments use this CGS request before facet joint interventions, including facet joint injections, medial branch blocks and radiofrequency ablation, for Original Medicare patients. Prior authorization is a condition of payment for these OPD services. The questions focus on anesthesia plans, imaging guidance, pain and function scales, conservative therapy and response to earlier procedures.

Who completes it

Hospital outpatient department staff complete the request with the OPD's PTAN, NPI and type of bill, the beneficiary, and the attending physician's name, NPI, fax and address, answering the clinical questions from the physician's documentation. CMS also lets a physician or practitioner submit on the hospital's behalf.

Submitting and payment

How to submit it
Submit before the service through myCGS (preferred), esMD, or by fax or mail using the Kentucky or Ohio line on the form. CGS decides in 7 calendar days, or 2 business days for justified expedited requests.
Who pays
The hospital reports the UTN on its Part A outpatient claim (type of bill 13X): an affirmed UTN means the claim will likely pay if other requirements are met, while a service billed with no UTN automatically denies.

Good to know

  • Documentation needs both a pain scale and a functional assessment scale, such as a numerical rating scale, visual analog scale, PDAS or PROMIS profile domains, used consistently.
  • For subsequent therapeutic procedures, records must show at least 50% pain relief for at least 3 months, or 50% improvement in previously painful movements and daily activities.
  • Plans for anesthesia beyond local anesthesia and anxiolytics, or a procedure without fluoroscopic or CT guidance, can lead to a non-affirmed decision.
  • Q4 asks whether conservative therapies were tried, such as NSAIDs, analgesics, a home exercise program or cognitive therapy. The form was originated March 13, 2023, and revised August 9, 2024.

Get the official form

Download the current version from the source each time; forms change without notice.

Prior Authorization OPD: Facet Joint Interventions

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

What pain relief does CGS require for repeat facet joint procedures?

For subsequent therapeutic procedures, Q5 asks whether documentation shows at least 50% pain relief for at least 3 months, or at least 50% consistent improvement in previously painful movements and activities of daily living compared with baseline, using the same scales. A No can lead to a non-affirmed decision.

Which scales satisfy the CGS facet joint form?

The form gives examples such as the numerical rating scale, visual analog scale, PDAS and PROMIS profile domains. It requires both a pain assessment scale and a functional assessment scale, and Q5 compares results with baseline using the same scales across visits.

How are codes entered on the facet joint request?

PAR 573 has one requested HCPCS field plus up to two related HCPCS codes. CGS notes that related codes need a primary code and any additional codes for the facet levels and region of the back being treated, along with a primary diagnosis code and the date of service.