Medicare coverage of SI joint fusion
Each Medicare Administrative Contractor (MAC) sets its own coverage policy. See where CPT codes 27278 and 27279 are covered, state by state.
Coverage Landscape by MAC
| MAC · LCD · effective | CPT Code 27278 All settings | CPT Code 27279 ASC & hospital | CPT Code 27279 Office |
|---|---|---|---|
NoridianL39810 · Eff. 4/17/25 | Not covered | Covered | Unknown |
Palmetto GBAL39797 · Eff. 4/17/25 | Not covered | Covered | Unknown |
CGSL39802 · Eff. 4/17/25 | Not covered | Covered | Unknown |
Wellpoint Federal (formerly NGS)L36406 · Eff. 4/1/16 | Not addressed | Covered | Unknown |
WPSL36000 · Eff. 12/17/15 | Not addressed | Covered | Unknown |
First CoastNo active LCD | No active LCD | No active LCD | Unknown |
NovitasNo active LCD | No active LCD | No active LCD | Unknown |
States in each jurisdiction are listed in the FAQ below. "Covered" means the MAC publishes an LCD with patient selection criteria for the code. "Not addressed" means the MAC's existing LCD does not specifically address coverage for the code or setting. "No active LCD" means the MAC has not established a coverage policy for the procedure. Claims without an applicable LCD coverage determination are evaluated on a claim-by-claim basis. Coverage is not guaranteed. CMS payment rates do not establish coverage. Dates shown are the LCD effective date or last revision. Policies change; confirm the current version in the Medicare Coverage Database before submitting.
Coverage of CPT code 27279 in the office is not yet known
Current Local Coverage Determinations (LCDs) address coverage for CPT code 27279 in a facility but do not address the office setting. Medicare pays for CPT code 27279 in the office from January 1, 2027. MACs typically update policy months after a fee schedule change takes effect. Confirm coverage and prior authorization requirements with each payer before scheduling.
Why three MACs restrict CPT code 27278
Noridian, Palmetto, and CGS consider arthrodesis without a transfixation device not reasonable and necessary, citing the absence of controlled studies (L39810, L39797, L39802). PainTEQ's clinical research program is designed to answer that question. Medicare Advantage and commercial plans apply their own policies.
Does Medicare cover minimally invasive SI joint fusion?
CPT code 27279 is addressed by every Medicare contractor in the ASC and hospital outpatient settings; no contractor has addressed the office setting. CPT code 27278 is covered by Wellpoint Federal, WPS, First Coast, and Novitas, and not covered by Noridian, Palmetto, or CGS.
Which MAC covers my state?
Noridian: AK, AZ, CA, HI, ID, MT, ND, NV, OR, SD, UT, WA, WY
Palmetto GBA: AL, GA, NC, SC, TN, VA, WV
CGS: KY, OH
Wellpoint Federal: CT, IL, MA, ME, MN, NH, NY, RI, VT, WI
WPS: IA, IN, KS, MI, MO, NE
First Coast: FL, PR, VI
Novitas: AR, CO, DC, DE, LA, MD, MS, NJ, NM, OK, PA, TX
Which states do not cover CPT Code 27278?
The twenty-two states under Noridian (AK, AZ, CA, HI, ID, MT, ND, NV, OR, SD, UT, WA, WY), Palmetto (AL, GA, NC, SC, TN, VA, WV), and CGS (KY, OH).
Does the 2027 office payment for CPT code 27279 change coverage?
No. A fee schedule states what Medicare pays when a service is covered; it does not indicate coverage. MAC criteria are unchanged, and current LCDs do not address the office setting.
Questions about coverage or prior authorization?
Coverage, coding, and payment are determined by individual payers and may vary by geography, plan, and patient. Sources: Medicare Coverage Database, LCDs L39810, L39797, L39802, L36406, L36000 and billing and coding articles; last verified November 2026.