CodeMap® LCD-L39025

Contractor Information

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

Contractor Number: 11502
Contractor Type: MAC B

LCD Information

LCD ID Number: L39025 Status: A-Approved
LCD Title: Minimally Invasive Surgical (MIS) Fusion of the Sacroiliac Joint (SIJ)
Geographic Jurisdiction: North Carolina Other Jurisdictions
Original Determination Effective Date: 07/17/2022
Original Determination Ending Date:
Revision Effective Date: 05/02/2023
Revision End Date:
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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