Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ) (L39812) - R2 - Effective April 17, 2025

Date Posted: October 9, 2025

This Local Coverage Determination (LCD) has been revised under contractor numbers: 02101 (AK), 02201 (ID), 02301 (OR), 02401 (WA), 03101 (AZ), 03201 (MT), 03301 (ND), 03401 (SD), 03501 (UT), and 03601 (WY).

Effective Date: April 17, 2025

Summary of Changes: Coverage Indications, Limitations and/or Medical Necessity - Covered Indications: A.1. - Corrected the LCD number for Sacroiliac Joint Injections and Procedures to L39462

Visit the Noridian Active LCDs webpage to view the Active LCD or access it via the CMS MCD.

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