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: 02102 (AK), 02202 (ID), 02302 (OR), 02402 (WA), 03102 (AZ), 03202 (MT), 03302 (ND), 03402 (SD), 03502 (UT), and 03602 (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.

Last Updated Oct 09 , 2025