Medicare local coverage
Medicare coverage for Sacroiliac Joint Injections and Procedures (LCD)
5 Medicare Administrative Contractors publish a local coverage determination (LCD) for Sacroiliac Joint Injections and Procedures. The snapshot lists 6 LCD records: 5 active, 1 retired.
An LCD applies only in the jurisdiction of the contractor that wrote it. Two contractors can cover the same service with different criteria, documentation requirements and covered diagnoses, so check the LCD from the contractor that processes your claims.
LCDs by contractor
| Contractor | LCD | Status | Last updated |
|---|---|---|---|
CGS Administrators, LLCMAC - Part A, MAC - Part B | L39383 | Active | Mar 27, 2026 |
Noridian Healthcare Solutions, LLCMAC - Part A, MAC - Part B | L39464 | Retired Mar 5, 2026 | Mar 5, 2026 |
Noridian Healthcare Solutions, LLCMAC - Part A, MAC - Part B | L39462 | Active | Feb 23, 2026 |
Palmetto GBAMAC - Part A, MAC - Part B | L39402 | Active | Nov 20, 2024 |
Wellpoint FederalMAC - Part A, MAC - Part B | L39455 | Active | Jul 14, 2026 |
WPS Insurance CorporationMAC - Part A, MAC - Part B | L39475 | Active | Dec 18, 2024 |
An LCD marked Future has been finalized and is in its notice period; it applies from the effective date shown. LCD IDs link to the record on cms.gov.
Billing and coding articles
The codes live in the billing and coding article that goes with each LCD: the CPT and HCPCS codes the policy applies to, the ICD-10 codes that support medical necessity, and any modifier or documentation rules.
- A59154CGS Administrators, LLCUpdated Mar 16, 2026
- A59192Palmetto GBAUpdated Nov 8, 2024
- A59233Wellpoint FederalUpdated Jul 14, 2026
- A59244Noridian Healthcare Solutions, LLCUpdated Feb 23, 2026
- A59246Noridian Healthcare Solutions, LLCUpdated Mar 5, 2026
- A59257WPS Insurance CorporationUpdated Dec 18, 2024
CMS also lists 5 response-to-comments articles for this topic, where contractors answer public comments on the proposed LCD: A59301, A59309, A59319, A59333, A59334.
Check claim lines against Medicare coverage
Coverage Check tells you whether a claim's diagnoses support Medicare LCD or NCD coverage for each procedure line, and shows the policy and CMS source behind each answer.
Related LCD topics
- Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ)
- Minimally-invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint
- Percutaneous minimally invasive fusion/stabilization of the sacroiliac joint for the treatment of back pain
- Peripheral Nerve Injections and Procedures for Chronic Pain
- Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
- Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow
All Medicare LCD topics · National coverage determinations · Payer policies by payer
Source: CMS Medicare Coverage Database, via the public CMS Coverage API, snapshot Oct 25, 2026. LCDs change between snapshots; confirm the version in effect for your date of service on cms.gov before billing.