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 A59695 (Billing and Coding: Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ)) 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.
A59695: Billing and Coding: Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ) (Billing and Coding, effective 2026-01-01)
- Covered ICD-10-CM codes
- 19
- 1 group
- Non-covered ICD-10-CM codes
- 0
- Procedure codes listed
- 2
- Full article
- cms.gov record
| ICD-10-CM | Description (FY2027) |
|---|---|
| M43.17 | — |
| M43.18 | — |
| M43.27 | — |
| M43.28 | — |
| M46.1 | — |
| M53.2X7 | — |
| M53.2X8 | — |
| M53.3 | — |
| M53.87 | — |
| M53.88 | — |
| M54.18 | — |
| M99.04 | — |
| M99.14 | — |
| S33.2XXA | — |
| S33.2XXD | — |
| S33.2XXS | — |
| S33.6XXA | — |
| S33.6XXD | — |
| S33.6XXS | — |
Procedure codes: 27278, 27279.
Coverage indications, limitations and medical necessity
Covered Indications
• Minimally Invasive (MI) Arthrodesis of the sacroiliac joint (SIJ) WITH placement of a transfixation device is considered medically reasonable and necessary when ALL of the following criteria are met:
• Patient must meet all requirements for coverage as outlined in Sacroiliac Joint Injections and Procedures L39462 including:
• At least 1 diagnostic block with ≥75% reduction of pain as defined in L39462 AND
• A trial of at least 1 therapeutic intra-articular SIJ injection (i.e., corticosteroid injection that results in a ≥50% reduction of pain for the expected duration of the injected agent AND
• Diagnostic imaging studies that include ALL the following:
• Imaging (plain radiographs and a computed tomography (CT) or magnetic resonance imaging (MRI)) of the SIJ that excludes the presence of destructive lesions (e.g., tumor, infection), fracture, traumatic SIJ instability, or inflammatory arthropathy that would not be properly addressed by percutaneous SIJ fusion (SIJF)
• Imaging of the pelvis (anteroposterior (AP) plain radiograph) to rule out concomitant hip pathology
• 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
• MI Arthrodesis of the SIJ WITHOUT placement of a transfixation device is NOT considered medically reasonable and necessary.
Limitations:
• Absence of generalized pain behavior (e.g., somatoform disorder) or generalized pain disorders (e.g., fibromyalgia)
• Patient should be part of an ongoing care plan, and be actively participating in a rehabilitation program, home exercise program or functional restoration program
Summary of evidence (opening)
The SIJ is a synovial or diarthrosis-amphiarthrosis joint, whose primary function is to transfer weight to and from the lower extremities to the axial skeleton. 1 The SIJ has been implicated as a source of chronic LBP in 15% to 30% of patients. 2 The SIJ contains both mechanoreceptors and nociceptive receptors such that SIJ pathology leads to pain in the buttocks, lower back, groin or leg. SIJ degeneration commonly occurs, especially after lumbar fusion. The SIJ is particularly enigmatic in its ability to mimic hip and lumbar spine pathology and also to result from the surgical treatment of hip and spine issues. 3 Patients with SIJ pain report Oswestry Disability Index (ODI) scores in the 50s and the burden of disease associated with SIJ pain is at least as high as that associated with other musculoskeletal conditions such as hip osteoarthritis, degenerative spondylolisthesis, or spinal stenosis; conditions that are often treated surgically. 4 Risk factors for SIJ dysfunction may include abnormal gait, scoliosis, degenerative and inflammatory arthritis, previous lumbar spinal surgery, trauma, and childbirth. 5 In addition, the SIJ may be a referred site of pain, including from a degenerative disc at L5-S1, spinal stenosis, or osteoarthritis of the hip.
Diagnosis remains problematic, with no universally accepted reference standard. Current best practice diagnostic techniques start with pain provocation testing. A positive result on 3 or more pain provocation tests, such as Gaenslen’s, FABER, compression, distraction, and thigh thrust, are used as criteria for further testing to confirm the SIJ as the primary pain generator. Typically, diagnostic blocks and intraarticular fluoroscopically guided injections are then used for confirmation of SIJ disorder. A standard of ≥75% relief of pain has been suggested as an indication of pain deriving from the SIJ. X-ray, CT or MRI of the SIJ has not proven to be sensitive or specific enough to be used alone but may be helpful when used in conjunction with other diagnostic techniques. Radiographic utility lies more in excluding the presence of other causes of pain that would not be properly addressed by percutaneous SIJF. 3,6,7
The mainstay of therapy for disorders of the SIJ has been nonoperative treatment, including activity modification, NSAIDs, physical therapy, radiofrequency neurotomy and SIJ injections (SIJIs). High quality clinical evidence corroborating the benefits of these non-surgical therapeutic options is limited by small patient populations, lack of placebo controls, and failure to utilize validated outcome measures. 8 When these modalities fail, the International Society for the Advancement of Spine Surgery (ISASS) recommends SIJ arthrodesis. 9 Surgical treatment is indicated for patients with a positive response to an SIJ injection with ≥75% relief, failure of nonsurgical treatment, and continued or recurrent SIJ pain.
Traditional open SIJF procedures are complex and invasive, involving open exposure of the joint with instrumented fixation and/or bone graft harvesting, and are typically associated with lengthy hospital stays, large blood loss and prolonged recovery times. Outcomes of traditional SIJF procedures were observed to be so poor with a high rate of reported non-union that these procedures were virtually abandoned over the last few decades. 10 However, in the case of revision surgery, nonunion, and aberrant anatomy, open arthrodesis should be performed. 11
The contractor cites 34 sources in the bibliography; the full summary and analysis of evidence are in the CMS record.
Dates, lineage and related policies
- Original determination effective
- 2025-04-17
- Current revision effective
- 2025-10-23
- MCD version
- 13
Other related documents: A59961 (Response to Comments), A59962 (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 Noridian Healthcare Solutions, LLC hub lists every other active policy from the same contractor.
The same policy title at other contractors
Contractors often adopt each other's policies and then revise them separately, so the criteria and the diagnosis lists drift apart. The topic comparison lines up every version.
Frequently asked questions
What does LCD L39810 cover?
• Patient must meet all requirements for coverage as outlined in Sacroiliac Joint Injections and Procedures L39462 including: 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 L39810 apply to?
Noridian Healthcare Solutions, LLC applies it to Medicare claims in AK, AS, AZ, CA, CNMI, GU, HI, ID, MT, ND, NF, NV, OR, SD, SF, UT, WA, 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 L39810?
The companion billing and coding article A59695 lists 19 ICD-10-CM codes in 1 group that support medical necessity; the first 19 appear on this page and the complete list is in the article on cms.gov.
How do I appeal a denial under LCD L39810?
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.