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: 02102 (AK), 02202 (ID), 02302 (OR), 02402 (WA), 03102 (AZ), 03202 (MT), 03302 (ND), 03402 (SD), 03502 (UT), and 03602 (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 Feb 05 , 2026