How Sacroiliac Ablation Found the Two MACs Without a Policy
Novitas and First Coast opened their first sacroiliac coverage policy for comment on November 5, closing December 19. The fifteen states and territories those two contractors pay hold 95.6 percent of Medicare's spending on sacroiliac radiofrequency ablation, a code every other contractor has called not reasonable and necessary since March 2023. The draft imports the session caps and the documentation rules and says nothing about the ablation.
Pull the CY2024 Medicare file for HCPCS 64625, radiofrequency ablation of the nerves innervating the sacroiliac joint, and sort the states by allowed dollars.
Florida. Texas. Maryland, Louisiana, Arkansas, Oklahoma, Pennsylvania, Colorado, Mississippi, New Mexico, New Jersey.
Eleven states, and the twelfth on the list bills a tenth of what the second one does.
Those eleven share something that has nothing to do with anybody's back. Every one of them is paid by Novitas Solutions or First Coast Service Options, the two A/B MAC contractors that have never written a sacroiliac coverage policy.
Last Thursday they wrote one.
The Code That Found the Gap
DL40417 from Novitas and DL40419 from First Coast went into the Medicare Coverage Database on October 30 and opened for comment on November 5. Both are titled "Sacroiliac Joint Nerve Blocks." Both are MAC-initiated, both carry an empty source-document field and a revision synopsis of "Not Applicable," which is the database saying there is nothing here to revise. Comments close December 19.
Between them the drafts reach twelve Novitas states plus the District of Columbia, and Florida, Puerto Rico and the Virgin Islands on the First Coast side. Fifteen jurisdictions.
Every other contractor has had this policy since March 19, 2023. CGS, Palmetto, Noridian twice, Wellpoint Federal and WPS, six final LCDs titled "Sacroiliac Joint Injections and Procedures," all carrying the same original effective date and the same sentence about ablation (chart below).
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