Sacroiliac Joint Injections and Procedures (L39464) - R1 - Effective March 19, 2023

Date Posted: February 5, 2026

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: March 19, 2023

Summary of Changes:

COVERAGE INDICATIONS:

Revised acronym radiofrequency (RF) ablation to radiofrequency (RFA) ablation

Removed the word "frequency" from the sentence: To clarify, a therapeutic SIJI session if performed on one side first and then on the opposite side at a different session would qualify as two (2) sessions for the limitation of four (4) therapeutic SIJ sessions per rolling 12 months.

SUMMARY OF EVIDENCE:

Revised spelling of the word "cryoanelgesia" to "cryoanalgesia"

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

Last Updated $dateUtil.getDate( $modifieddate , "MMM dd , yyyy" , $locale , $tzone )