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Contractor Information

Contractor Name: Palmetto GBA - Full list of policies of this Medicare Contractor Contractor Number: 10111 Contractor Type: MAC A

LCD Information

LCD ID Number: L39402 Status: A-Approved LCD Title: Sacroiliac Joint Injections and Procedures Geographic Jurisdiction: Alabama Other Jurisdictions Original Determination Effective Date: 03/19/2023 Original Determination Ending Date: Revision Effective Date: 11/28/2024 Revision End Date: CMS National Coverage Policy: This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for SACROILIAC procedures for pain management. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for SACROILIAC procedures for pain management and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies may be found in the following Internet-Only Manuals (IOMs) published on the CMS Website: CMS Internet-Only Manual Pub. 100-08, Medicare Program Integrity Manual, Chapter 13, §13.5.4 Reasonable and Necessary Provisions in LCDs Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Title XVIII of the Social Security Act, §1862(a)(7) states Medicare will not cover any services or procedures associated with routine physical examinations. Title XVIII of the Social Security Act, §1861(s)(2) Part E – Miscellaneous Provisions: Definitions of Services, etc. 42 CFR §410.74 Physician assistants’ services, §410.75 Nurse practitioners’ services and §410.76 Clinical nurse specialists’ services Sorry, you need to login or register to view additional sections of this Medicare policy. *