CodeMap® LCD-L39025

Contractor Information

Contractor Name: Palmetto GBA - Full list of policies of this Medicare Contractor

Contractor Number: 11202
Contractor Type: MAC B

LCD Information

LCD ID Number: L39025 Status: R- Retired
LCD Title: Minimally Invasive Surgical (MIS) Fusion of the Sacroiliac Joint (SIJ)
Geographic Jurisdiction: South Carolina Other Jurisdictions
Original Determination Effective Date: 07/17/2022
Original Determination Ending Date: 04/16/2025
Revision Effective Date: 05/02/2023
Revision End Date: 04/16/2025
CMS National Coverage Policy:
Title XVIII of the Social Security Act (SSA), §1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

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05/13/2025 07:48:01 18.97.9.173

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