Traditional MedicareCoverageHigh impact
Minimally-invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint
Medicare/CMS - LCD·Orthopedics, Neurosurgery, General Surgery·Local Coverage Determination
Effective date
Apr 1, 2026
We identified it
Jul 28, 2026
Summary
This is a new Local Coverage Determination (LCD L36406) from Wellpoint Federal establishing Medicare coverage policy for minimally-invasive surgical (MIS) fusion of the sacroiliac (SI) joint, effective April 1, 2026. The policy applies to both MAC Part A and Part B claims. Billing teams must review the full policy text to identify covered diagnoses, medical necessity requirements, and any prior authorization mandates before submitting claims for SI joint fusion procedures.
Action Required
By March 31, 2026: Billing and clinical teams must review the complete LCD L36406 policy at https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=36406&ver=10 to identify: (1) specific CPT codes covered for MIS SI joint fusion, (2) medical necessity documentation requirements, (3) prior authorization requirements, and (4) any covered diagnosis codes (ICD-10). Update billing system rules, encounter templates, and provider documentation guidelines accordingly. Communicate coverage requirements to orthopedic and spine surgery providers. Failure to comply with coverage criteria will result in claim denials for Medicare beneficiaries served by Wellpoint Federal in applicable regions.