Where this LCD applies
Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.
Billing and coding: diagnoses and procedure codes
Since 2019 the codes live in the companion article rather than the LCD. Billing and Coding A57596 (Billing and Coding: Percutaneous minimally invasive fusion/stabilization of the sacroiliac joint for the treatment of back pain) carries the diagnosis and procedure lists the contractor loads as the claims edit. CPT codes are shown as bare numbers because the descriptors are licensed by the AMA; HCPCS Level II descriptors are public and shown.
A57596: Billing and Coding: Percutaneous minimally invasive fusion/stabilization of the sacroiliac joint for the treatment of back pain (Billing and Coding, effective 2026-01-01)
- Covered ICD-10-CM codes
- 11
- 1 group
- Non-covered ICD-10-CM codes
- 0
- Procedure codes listed
- 1
- Full article
- cms.gov record
| ICD-10-CM | Description (FY2027) |
|---|---|
| M43.18 | — |
| M46.1 | — |
| M53.3 | — |
| M53.88 | — |
| M99.04 | — |
| Q74.2 | — |
| S33.2XXA | — |
| S33.2XXD | — |
| S33.2XXS | — |
| S33.6XXD | — |
| S33.6XXS | — |
Procedure codes: 27279.
Coverage indications, limitations and medical necessity
The sacroiliac (SI) joints are formed by the connection of the sacrum and the right and left iliac bones. The sacrum is the triangular-shaped bone in the lower portion of the spine, below the lumbar spine. While most of the bones (vertebrae) of the spine are mobile, the sacrum is made up of 5 vertebrae that are fused together and do not move. The iliac bones are the 2 large bones that make up the pelvis. As a result, the SI joints connect the spine to the pelvis. The sacrum and the iliac bones (ileum) are held together by a collection of strong ligaments. There is relatively little motion at the SI joints. There are normally less than 4 degrees of rotation and 2 mm of translation at these joints.
Indications
Percutaneous minimally invasive fusion/stabilization of the sacroiliac joint (SIJ) for the treatment of back pain is indicated for the treatment of SIJ pain for patients with low back/buttock pain who meet all of the following criteria:
a) Have undergone and failed a minimum 6 months of intensive non-operative treatment that must include medication optimization, activity modification, and active physical therapy;
b) Patient’s report of non-radiating, unilateral pain that is caudal to the lumbar spine (L5 vertebrae), localized over the posterior SIJ, and consistent with SIJ pain;
c) Localized tenderness with palpation of the posterior SIJ in the absence of tenderness of similar severity elsewhere (e.g. greater trochanter, lumbar spine, coccyx) and other obvious sources for their pain do not exist;
d) Positive response to the thigh thrust test OR compression test AND 2 of the following additional provocative tests: Gaenslen’s test, Distraction test, Patrick’s sign;
e) Absence of generalized pain behavior (e.g. somatoform disorder) or generalized pain disorders (e.g. fibromyalgia);
f) Diagnostic imaging studies that include ALL of the following:
1. Imaging (plain radiographs and a CT or MRI) of the SI joint that excludes the presence of destructive lesions (e.g. tumor, infection) or inflammatory arthropathy that would not be properly addressed by percutaneous SIJ fusion;
2. Imaging of the ipsilateral hip (plain radiographs) to rule out osteoarthritis;
3. Imaging of the lumbar spine (CT or MRI) to rule out neural compression or other degenerative condition that can be causing low back or buttock pain;
g) At least 75% reduction of pain for the expected duration of the anesthetic used following an image-guided, contrast-enhanced SIJ injection on 2 separate occasions.
Limitations
Percutaneous SIJ fusion for SIJ pain is not indicated in the presence of:
Systemic arthropathy such as ankylosing spondylitis or rheumatoid arthritis;
Generalized pain behavior (e.g. somatoform disorder) or generalized pain disorder (e.g. fibromyalgia);
Infection, tumor, or fracture;
Acute, traumatic instability of the SIJ;
Neural compression as seen on an MRI or CT that correlates with the patient’s symptoms or other more likely source for their pain.
Summary of evidence (opening)
N/A
the full summary and analysis of evidence are in the CMS record.
Dates, lineage and related policies
- Original determination effective
- 2015-12-17
- Current revision effective
- 2024-06-27
- Last reviewed by the contractor
- 2026-04-29
- MCD version
- 21
Other related documents: A54694 (Response to Comments).
Using this policy on a claim
Match the documented indication to the covered indications above before the service is scheduled, carry a diagnosis from the article's covered list on the claim line, and keep the elements the documentation section asks for in the record, because the contractor can request it later through medical review. A denial under this policy arrives as CARC 50 with remark N115; the LCD lookup guide walks through the appeal path and the Advance Beneficiary Notice rules, and the Wisconsin Physicians Service Insurance Corporation hub lists every other active policy from the same contractor.
Frequently asked questions
What does LCD L36000 cover?
The sacroiliac (SI) joints are formed by the connection of the sacrum and the right and left iliac bones. The sacrum is the triangular-shaped bone in the lower portion of the spine, below the lumbar spine. While most of the bones (vertebrae) of the spine are mobile, the sacrum is made up of 5 vertebrae that are fused together and do not move. The iliac bones are the 2 large bones that make up the pelvis. As a… The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database export of September 24, 2026.
Which states does LCD L36000 apply to?
Wisconsin Physicians Service Insurance Corporation applies it to Medicare claims in AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY. A Local Coverage Determination binds only the contractor that wrote it; the same service in another jurisdiction is judged under that contractor's own policy or, where none exists, claim by claim.
Which diagnosis codes support medical necessity under LCD L36000?
The companion billing and coding article A57596 lists 11 ICD-10-CM codes in 1 group that support medical necessity; the first 11 appear on this page and the complete list is in the article on cms.gov.
How do I appeal a denial under LCD L36000?
The remittance carries claim adjustment reason code 50 with remark code N115, naming the LCD. Compare the documented indication with the policy's covered indications and the article's diagnosis list, then file a redetermination within 120 days with the record attached; if the service genuinely falls outside the policy, the patient can be billed only when a valid Advance Beneficiary Notice was obtained before the service.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.
- Medicare Coverage Database, current LCD exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file lcd.csvSHA-256 2fcc4251b6ddd1eb…
- Medicare Coverage Database, current Billing and Coding Articles exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file article.csvSHA-256 f31932f1df3b4035…
- ICD-10-CM FY2027 code descriptionsVersion FY2027 · effective 2026-10-01 · file icd10cm_codes_2027.txtSHA-256 3c0583a38ee0e848…
Disclaimer
The policy text and code lists are reproduced from the CMS Medicare Coverage Database export as an operational reference. Verify against the current LCD and article on cms.gov before billing; coverage depends on the full record and the contractor. Not legal, clinical or billing advice.