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Sacroiliac Joint Fusion

Policy Number: MP-555

 Latest Review Date: December 2019

Category: Surgery                                                                  

Policy Grade:  B

POLICY:

Effective for dates of service on or after March 18, 2019:

Minimally invasive fusion/stabilization of the sacroiliac joint using an FDA approved device may be considered medically necessary when ALL of the following criteria are met:

  1. Pain is at least 5 on a 0 to 10 rating scale that impacts quality of life or limits activities of daily living; AND
  2. There is an absence of generalized pain behavior (e.g., somatoform disorder) or generalized pain disorders (e.g., fibromyalgia); AND
  3. Patients have undergone and failed a minimum 6 months of intensive nonoperative treatment that must include medication optimization, activity modification, bracing, and active therapeutic exercise targeted at the lumbar spine, pelvis, sacroiliac joint, and hip, including a home exercise program; AND
  4. Pain is caudal to the lumbar spine (L5 vertebra), localized over the posterior sacroiliac joint, and consistent with sacroiliac joint pain; AND
  5. A thorough physical examination demonstrates localized tenderness with palpation over the sacral sulcus (Fortin’s point) in the absence of tenderness of similar severity elsewhere; AND
  6. There is a positive response to a cluster of 3 provocative tests (e.g., thigh thrust test, compression test, Gaenslen sign, distraction test, Patrick test, posterior provocation test); AND
  7. Diagnostic imaging studies include ALL of the following:
    1. Imaging (plain radiographs and computed tomography or magnetic resonance imaging) of the sacroiliac joint excludes the presence of destructive lesions (e.g., tumor, infection) or inflammatory arthropathy of the sacroiliac joint; AND
    2. Imaging of the pelvis (anteroposterior plain radiograph) rules out concomitant hip pathology; AND
    3. Imaging of the lumbar spine (computed tomography or magnetic resonance imaging) is performed to rule out neural compression or other degenerative condition that can be causing low back or buttock pain; AND
    4. Imaging of the sacroiliac joint indicates evidence of injury and/or degeneration; AND
  8. There is at least a 75% reduction in pain for the expected duration of the anesthetic used following an image-guided, contrast-enhanced intra-articular sacroiliac joint injection on 2 separate occasions; AND
  9. A trial of a therapeutic sacroiliac joint injection (i.e., corticosteroid injection) has been performed on at least once.

Minimally invasive fusion/stabilization of the sacroiliac joint is not medically necessary and investigational for all other indications.

Sacroiliac joint fusion, performed by an open procedure, may be considered medically necessary when ONE of the following criterion is met:

  • as an adjunct to sacrectomy or partial sacrectomy related to tumors involving the sacrum; OR
  • as an adjunct to the medical treatment of sacroiliac joint infection (e.g., osteomyelitis; pyogenic sacroiliitis) or sepsis;

OR

  • as a treatment for severe traumatic injuries associated with pelvic ring fracture.

Sacroiliac joint fusion performed by an open procedure for any other indication not listed above is considered not medically necessary and investigational.

 

Effective for dates prior to March 18, 2019:

Sacroiliac joint fusion, performed by an open procedure, may be considered medically necessary when one of the following criteria is met:

  • as an adjunct to sacrectomy or partial sacrectomy related to tumors involving the sacrum; OR
  • as an adjunct to the medical treatment of sacroiliac joint infection (e.g., osteomyelitis; pyogenic sacroiliitis) or sepsis;

OR

  • as a treatment for severe traumatic injuries associated with pelvic ring fracture.

Sacroiliac joint fusion, performed by an open procedure, for any other indication not listed above; including but not limited to the treatment of mechanical low back pain, arthritis, or any other type of back pain, is considered not medically necessary and investigational.

Sacroiliac joint fusion, performed by percutaneous or minimally invasive techniques, is considered not medically necessary and investigational.

DESCRIPTION OF PROCEDURE OR SERVICE:

Sacroiliac joint fusion is a surgical procedure which fuses the iliac bone (pelvis) to the spine (sacrum) for stabilization. It is performed for a variety of conditions including trauma, infection, cancer, and spinal instability. Similar to other structures in the spine, it is assumed that the sacroiliac joint may be a source of low back pain. Fusion of the sacroiliac joint was initially described as a treatment option for low back pain in 1925. Given the depth of and anatomic location of the SI joint, significant morbidity was associated with open fusion approach and limited usage of these procedures.

Research into sacroiliac joint pain has been thwarted by any criterion standard to measure its prevalence and against which various clinical examinations can be validated. For example, sacroiliac joint pain is typically without any consistent, demonstrable radiographic or laboratory features and most commonly exists in the setting of morphologically normal joints. Clinical tests for sacroiliac joint pain may include various movement tests, palpation to detect tenderness, and pain descriptions by the patient. Further confounding study of the sacroiliac joint is that multiple structures, such as posterior facet joints and lumbar discs, may refer pain to the area surrounding the sacroiliac joint.

Because of inconsistent information obtained from history and physical examination, some have proposed the use of image-guided anesthetic injection into the SIJ for the diagnosis of SIJ pain. Treatments being investigated for SIJ pain include prolotherapy (refer to policy # 235 Prolotherapy), corticosteroid injection, radiofrequency ablation, stabilization, and arthrodesis. For indications and coverage criteria related to diagnosis and other treatments of SIJ pain, refer to policy #558 Diagnosis and Treatment of Sacroiliac Joint Pain.

Over the past few decades, techniques utilizing trans-iliac approaches to fuse the sacroiliac joint have been developed. Minimally invasive technology has been applied to these approaches and has resulted in the development of percutaneous SI joint fusion procedures in recent years.Some procedures have been referred to as SIJ fusion but may be more appropriately called fixation (this is because there is little to no bridging bone on radiographs). Devices for SIJ fixation/fusion that promote bone ingrowth to fixate the implants include a triangular implant (iFuse Implant System) and cylindrical threaded devices (Rialto, SImmetry, Silex, SambaScrew, SI-LOK). Some devices also have a slot in the middle where autologous or allogeneic bone can be inserted. This added bone is intended to promote fusion of the SIJ.

KEY POINTS:

The most recent literature review was performed through August 28, 2019. Following is a summary of key references to date.

Summary of Evidence

For individuals who SIJ pain who receive SIJ fusion/fixation with a triangular implant, the evidence includes 2 nonblinded RCTs of minimally invasive fusion and 2 case series with more than 85% follow-up at 2 to 3 years. Relevant outcomes are symptoms, functional outcomes, quality of life, medication use, and treatment-related morbidity. Both RCTs reported superior short-term results for fusion, however, a preferable design for assessing pain outcomes would be independent, blinded assessment of outcomes or, when feasible, a sham-controlled trial. Longer term follow-up from these RCTs has indicated that the results obtained at 6 months persist to 2 years. An additional cohort study and case series, with sample sizes ranging from 45 to 149 patients and low dropout rates (<15%), have also shown reductions in pain and disability at 2 years. One small case series showed outcomes that persisted to 5 years. These cohort studies and case series are consistent with the durability of treatment benefit, but only if there is a true benefit of treatment. Analysis of an insurance database reported an overall incidence of complications to be 16.4% at 6 months and cumulative revision rate at 4 years of 3.54%. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals who have SIJ pain who receive SIJ fusion/fixation with a cylindrical threaded implant, the evidence includes a prospective cohort. Relevant outcomes are symptoms, functional outcomes, quality of life, medication use, and treatment-related morbidity. The prospective cohort study will follow patients for 2 years following implantation of slotted screws filled with autologous bone. Results at 1 year are consistent with findings from the studies using a triangular implant. However, longer follow-up and controlled trials are needed to evaluate this type of implant. The evidence is insufficient to determine the effects of the technology on health outcomes.

Practice Guidelines and Position Statements

In response to requests, focused input on SIJ fusion was received from 5 physician specialty societies and 3 academic medical centers while this policy was under review in 2015. A majority of reviewers considered SIJ fusion to be investigational.

International Society for the Advancement of Spine Surgery (ISASS)

The International Society for the Advancement of Spine Surgery (ISASS) published a policy statement on minimally invasive sacroiliac joint fusion in 2014. These recommendations were updated in a 2016 statement. ISASS has specific criteria for patients who may be eligible for minimally invasive sacroiliac joint fusion. These recommendations may be found on the ISASS website.

North American Spine Society

The North American Spine Society (NASS) published coverage recommendations for percutaneous sacroiliac joint (SIJ) fusion in 2015. NASS indicated that there was relatively moderate evidence. In the absence of high-level data, NASS policies reflect the multidisciplinary experience and expertise of the committee members in order to present reasonable standard practice indications in the United States. NASS recommended coverage when all of the following criteria are met:

  1. “[Patients] have undergone and failed a minimum 6 months of intensive nonoperative treatment that must include medication optimization, activity modification, bracing and active therapeutic exercise targeted at the lumbar spine, pelvis, SIJ and hip including a home exercise program.
  2. Patient’s report of typically unilateral pain that is caudal to the lumbar spine (L5 vertebra), localized over the posterior SIJ, and consistent with SIJ pain.
  3. A thorough physical examination demonstrating localized tenderness with palpation over the sacral sulcus (Fortin’s point, i.e., at the insertion of the long dorsal ligament inferior to the posterior superior iliac spine or PSIS) in the absence of tenderness of similar severity elsewhere (e.g., greater trochanter, lumbar spine, coccyx) and that other obvious sources for their pain do not exist.
  4. Positive response to a cluster of 3 provocative tests (e.g., thigh thrust test, compression test, Gaenslen’s test, distraction test, Patrick’s sign, posterior provocation test). Note that the thrust test is not recommended in pregnant patients or those with connective tissue disorders.
  5. Absence of generalized pain behavior (e.g., somatoform disorder) or generalized pain disorders (e.g., fibromyalgia).
  6. Diagnostic imaging studies that include ALL of the following:
    1. Imaging (plain radiographs and a CT [computed tomography] or MRI [magnetic resonance imaging]) of the SI joint that excludes the presence of destructive lesions (e.g., tumor, infection) or inflammatory arthropathy that would not be properly addressed by percutaneous SIJ fusion.
    2. Imaging of the pelvis (AP [anteroposterior] plain radiograph) to rule out concomitant hip pathology.
    3. Imaging of the lumbar spine (CT or MRI) to rule out neural compression or other degenerative condition that can be causing low back or buttock pain.
    4. Imaging of the SI joint that indicates evidence of injury and/or degeneration.
  7. At least 75% reduction of pain for the expected duration of the anesthetic used following an image-guided, contrast-enhanced intra-articular SIJ injection on 2 separate occasions.
  8. A trial of at least one therapeutic intra-articular SIJ injection (i.e., corticosteroid injection).”

National Institute for Health and Care Excellence

National Institute for Health and Care Excellence guidance was published in 2017 on minimally invasive SIJ fusion surgery for chronic sacroiliac pain. The recommendations included:

  1. “Current evidence on the safety and efficacy of minimally invasive sacroiliac (SI) joint fusion surgery for chronic SI pain is adequate to support the use of this procedure…. provided that standard arrangements are in place for clinical governance, consent and audit.
  2. Patients having this procedure should have a confirmed diagnosis of unilateral or bilateral SI joint dysfunction due to degenerative sacroiliitis or SI joint disruption.
  3. This technically challenging procedure should only be done by surgeons who regularly use image-guided surgery for implant placement. The surgeons should also have had specific training and expertise in minimally invasive SI joint fusion surgery for chronic SI pain.”

 

U.S. Preventive Services Task Force Recommendations

Not Applicable.

KEY WORDS:

Sacroiliac Joint Arthrodesis, SInergy, SI sacroiliac joint stabilization for arthrodesis, SI-FIX Sacroiliac Joint Fusion System ,IFUSE Implant System, SImmetry Sacroiliac Joint Fusion System and the SI-LOK, Minimally invasive sacroiliac joint fusion, percutaneous sacroiliac joint fusion, Silex, XTANT, SambaScrew, Si Bone, titanium triangular implant

APPROVED BY GOVERNING BODIES:

A number of percutaneous or minimally invasive fixation/fusion devices have been cleared for marketing by the FDA through the 510(k) process. They include the iFuse® Implant System (SI Bone), the Rialto™ SI Joint Fusion System (Medtronic), SIJ-Fuse (Spine Frontier), the SImmetry® Sacroiliac Joint Fusion System (Zyga Technologies), Silex™ Sacroiliac Joint Fusion System (XTANT Medical), SambaScrew® (Orthofix), and the SI-LOK® Sacroiliac Joint Fixation System (Globus Medical).

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits.  Group specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply.

FEP:  Special benefit consideration may apply.  Refer to member’s benefit plan.  FEP does not consider investigational if FDA approved and will be reviewed for medical necessity.

CURRENT CODING: 

CPT Codes:

22899

Unlisted procedure, spine

27279

Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device

27280

Arthrodesis, open, sacroiliac joint, including obtaining bone graft, including instrumentation, when performed

27299

Unlisted procedure, pelvis or hip joint

REFERENCES:

  1. American Society of Anesthesiologists Task Force on Chronic Pain Management, American Society of Regional Anesthesia and Pain Medicine. Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology. Apr 2010; 112(4):810-833.
  2. Ackerman SJ et al. Comparison of the costs of nonoperative care to minimally invasive surgery for sacroiliac joint disruption and degenerative sacroiliitis in a United States Medicare population: potential economic implications of a new minimally-invasive technology. Clinicoecon Outcomes Res. 2013; 5:575-587.
  3. Araghi A, Woodruff R, Colle K, et al. Pain and opioid use outcomes following minimally invasive sacroiliac joint fusion with decortication and bone grafting: The Evolusion Clinical Trial. Open Orthop J. Feb 2017;11:1440-1448.
  4. Ashman B, Norvell DC, Hermsmeyer JT. Chronic sacroiliac joint pain: fusion versus denervation as treatment options. Evid Based Spine Care J 2010; 1(3):35-44.
  5. Boswell MV, Trescot AM, Datta S et al. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician 2007; 10(1):7-111.
  6. Cher DJ, Reckling WC, Capobianco RA. Implant survivorship analysis after minimally invasive sacroiliac joint fusion using the iFuse Implant System((R)). Med Devices (Auckl). Dec 2015; 8:485-492.
  7. Chou R, Loeser JD, Owens DK et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine (Phila Pa 1976) 2009; 34(10):1066-1077.
  8. Cross WW, Delbridge A, Hales D, et al. Minimally Invasive sacroiliac joint fusion: 2-year radiographic and clinical outcomes with a principles-based SIJ fusion system. Open Orthop J. Feb 2018;12:7-16.
  9. Darr E, Meyer SC, Whang PG, et al. Long-term prospective outcomes after minimally invasive trans-iliac sacroiliac joint fusion using triangular titanium implants. Med Devices (Auckl). 2018;11:113-121.
  10. Dengler JD, Kools D, Pflugmacher R, et al. 1-Year results of a randomized controlled trial of conservative management vs. minimally invasive surgical treatment for sacroiliac joint pain. Pain Physician. Sep 2017; 20(6):537-550.
  11. Dengler J, Sturesson B, Kools D, et al. Referred leg pain originating from the sacroiliac joint: 6-month outcomes from the prospective randomized controlled iMIA trial. Acta Neurochir (Wien). Nov 2016; 158(11):2219-2224.
  12. Dreyfuss P, Michaelsen M, Pauza K et al. The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine (Phila Pa 1976) 1996; 21(22):2594-2602.
  13. Duhon et al. Safety and 6-month effectiveness of minimally invasive sacroiliac joint fusion: a prospective study. Med Dev (Auckl) 2013; 6:219-229.
  14. Duhon BS, Bitan F, Lockstadt H, et al. Triangular titanium implants for minimally invasive sacroiliac joint fusion: 2-year follow-up from a prospective multicenter trial. Int J Spine Surg. 2016; 10:13.
  15. Duhon B, Cher D, Wine, KD, et al. Triangular titanium implants for minimally invasive sacroiliac joint fusion: a prospective study. Global Spine J. May 2016; 6(3):257-269.
  16. Graham-Smith et al. Open versus minimally invasive sacroiliac joint fusion: a multi-center comparison of perioperative measures and clinical outcomes. Ann Surg Innov Res 2013; 7:1-12.
  17. Hansen HC, McKenzie-Brown AM, Cohen SP, et al. Sacroiliac joint interventions: a systematic review. Pain Physician. Jan 2007; 10(1):165-184.
  18. Hansen H, Manchikanti L, Simopoulos TT, et al. A systematic evaluation of the therapeutic effectiveness of sacroiliac joint interventions. Pain Physician. May-Jun 2012; 15(3):E247-278.
  19. Heiney J, Capobianco R, Cher D. A systematic review of minimally invasive sacroiliac joint fusion using lateral transarticular technique. Intern J of Spine 2015; 9(40).
  20. International Society for the Advancement of Spine Surgery (ISASS) statement on minimally invasive SI joint fusion coding changes. www.isass.org/public_policy/2013-08-07-isass-statement-minimally-invasive-si-joint-fusion-coding-changes.html.
  21. International Society for the Advancement of Spinal Surgery (IASS). Recommendations for Coverage Criteria for Sacroiliac Joint Fusion. 2015; www.isass.org/public_policy/2015-03-19-coverage-criteria-for-minimallyinvasive-si-joint-fusion-2015.html.
  22. International Society for the Advancement of Spinal Surgery (ISASS). ISASS policy 2016 update- minimally invasive sacroilliac joint fusion. 2016; www.isass.org/public-policy/isass-policy-statement-minimally-invasive-sacroiliac-joint-fusion-july-2016/.
  23. Lorio MP, Rashbaum R. ISASS policy statement - minimally invasive sacroiliac joint fusion. Int J Spine Surg. 2014; 8.
  24. Manchikanti L, Abdi S, Atluri S, et al. An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain Physician. Apr 2013; 16(2Suppl):S49-283.
  25. Manchikanti L, Boswell MV, Singh V et al. Comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician 2009; 12(4):699-802.
  26. Manchikanti L, Datta S, Derby R, et al. A critical review of the American Pain Society clinical practice guidelines for interventional techniques: part 1. Diagnostic interventions. Pain Physician. May-Jun 2010; 13(3):E141-174.
  27. Manchikanti L, Datta S, Gupta S, et al. A critical review of the American Pain Society clinical practice guidelines for interventional techniques: part 2. Therapeutic interventions. Pain Physician. Jul-Aug 2010; 13(4):E215-264.
  28. Mason LW, Chopra I, Mohanty K. The percutaneous stabilisation of the sacroiliac joint with hollow modular anchorage screws: a prospective outcome study. Eur Spine J 2013; 22(10):2325-2331.
  29. Miller L et al. Analysis of the postmarket complaints database for the iFuse SI Joint Fusion System®: a minimally invasive treatment for degenerative sacroiliitis and sacroiliac joint disruption. Med Device (Auckl) 2013; 6:77-84.
  30. North American Spine Society (NASS). NASS coverage policy recommendations: Percutaneous sacroiliac joint fusion. 2015; https://www.spine.org/PolicyPractice/CoverageRecommendations/CoverageRecommendations.aspx.
  31. Polly DW, Cher DJ, Wine KD, et al. Randomized Controlled Trial of Minimally Invasive Sacroiliac Joint Fusion Using Triangular Titanium Implants vs Nonsurgical Management for Sacroiliac Joint Dysfunction: 12-Month Outcomes. Neurosurgery. Nov 2015; 77(5):674-691.
  32. Polly D, Swofford J, Whang P, et al. Two-year outcomes from a randomized controlled trial of minimally invasive sacroiliac joint fusion vs non-surgical management for sacroiliac joint dysfunction. Int J Spine Surg. 2016; 10:28.
  33. Rappoport LH, Luna IY, Joshua G. Minimally Invasive sacroiliac joint fusion using a novel hydroxyapatite-coated screw: preliminary 1-year clinical and radiographic results of a 2-year prospective study. World Neurosurg. May 2017; 101:493-497.
  34. Rudolf L. Sacroiliac Joint Arthrodesis-MIS Technique with Titanium Implants: Report of the First 50 Patients and Outcomes. Open Orthop J 2012; 6:495-502.
  35. Rudolf L. MIS sacroiliac (SI) joint fusion in the context of previous lumbar spine fusion: 5 patients with 24 month follow up. In Int. Soc. Adv. Spine Surg. 107(2013).
  36. Rudolf L, Capobianco R. Five-year clinical and radiographic outcomes after minimally invasive sacroiliac joint fusion using triangular implants. Open Orthop J. 2014; 8:375-383.
  37. Rupert MP, Lee M, Manchikanti L et al. Evaluation of sacroiliac joint interventions: a systematic appraisal of the literature. Pain Physician 2009; 12(2):399-418.
  38. Sachs D, Capobianco R. One year successful outcomes for novel sacroiliac joint arthrodesis system. Ann Surg Innov Res 2012; 6(1):13.
  39. Sachs D, Capobianco R, Cher D, et al. One-year outcomes after minimally invasive sacroiliac joint fusion with a series of triangular implants: a multicenter, patient-level analysis. Med Devices (Auckl). 2014; 7:299-304.
  40. Sachs D, Kovalsky D, Redmond A, et al. Durable intermediate-to long-term outcomes after minimally invasive transiliac sacroiliac joint fusion using triangular titanium implants. Med Devices (Auckl). 2016; 9:213-222.
  41. Schoell K, Buser Z, Jakoi A, et al. Postoperative complications in patients undergoing minimally invasive sacroiliac fusion. Spine J. Nov 2016; 16(11):1324-1332.
  42. Schwarzer AC, Aprill CN, Bogduk N. The sacroiliac joint in chronic low back pain. Spine (Phila Pa 1976) 1995; 20(1):31-37.
  43. Smith AG, Capobianco R, Cher D et al. Open versus minimally invasive sacroiliac joint fusion: a multi-center comparison of perioperative measures and clinical outcomes. Ann Surg Innov Res. Oct 30 2013; 7(1):14.
  44. Spain K, Holt T. Surgical revision after sacroiliac joint fixation or fusion. Int J Spine Surg. Apr 2017; 11:5.
  45. Spiker WR, Lawrence BD, Raich AL et al. Surgical versus injection treatment for injection-confirmed chronic sacroiliac joint pain. Evid Based Spine Care J 2012; 3(4):41-53.
  46. Sturesson B, Kools D, Pflugmacher R, et al. Six-month outcomes from a randomized controlled trial of minimally invasive SI joint fusion with triangular titanium implants vs conservative management. Eur Spine J. Mar 2017; 26(3):708-719.
  47. Tran ZV, Ivashchenko A, Brooks L. Sacroiliac Joint Fusion Methodology - Minimally Invasive Compared to Screw-Type Surgeries: A Systematic Review and Meta-Analysis. Pain Physician, 2019 Feb 1;22(1).
  48. Vanaclocha V, Herrera JM, Saiz-Sapena N, et al. Minimally invasive sacroiliac joint fusion, radiofrequency denervation, and conservative management for sacroiliac joint pain: 6-year comparative case series. Neurosurgery. Apr 20 2017.
  49. Weksler N, Velan GJ, Semionov M et al. The role of sacroiliac joint dysfunction in the genesis of low back pain: the obvious is not always right. Arch Orthop Trauma Surg 2007; 127(10):885-888.
  50. Whang P, Cher D, Polly D, et al. Randomized Controlled Trial of Minimally Invasive Sacroiliac Joint Fusion Using Triangular Titanium Implants vs. Non-Surgical Management for Sacroiliac Joint Dysfunction: 12 month Outcomes. Neurosurgery 2015.
  51. Whang P, Cher D, Polly D, et al. Sacroiliac Joint Fusion Using Triangular Titanium Implants vs. Non-Surgical Management: Six-Month Outcomes from a Prospective Randomized Controlled Trial. Int J Spine Surg. 2015; 9:6.
  52. Wise CL, Dall BE. Minimally invasive sacroiliac arthrodesis: outcomes of a new technique. J Spinal Disord Tech 2008; 21(8):579-584.

POLICY HISTORY:

Medical Policy Panel February 2014

Medical Policy Group, February 2014

Medical Policy Administration Committee, February 2014

Available for comment March 7 through April 20, 2014

Medical Policy Group, June 2014 (4): Added more References

Medical Policy Panel, May 2014

Medical Policy Group, September 2014 (3):  2014 Updates to Key Points, Key Words, Governing Bodies & References; no change in policy statement

Medical Policy Group, November 2014: 2015 Annual Coding Update – verbiage change to code 27280 to add ‘open’ and ‘including instrumentation when performed’. Also added code 27279 to current coding and created Previous Coding section to include deleted code 0334T.

Medical Policy Panel, May 2015

Medical Policy Group, September 2015 (2): 2015 Updates to Key Points and References; no change to policy statement.

Medical Policy Panel, November 2015

Medical Policy Group, November 2015 (2): 2015 Updates to Key Points and References; no change to policy statement.

Medical Policy Panel, October 2016

Medical Policy Group, October 2016 (7): 2016 Updates to Key Points and References; no change to policy statement.

Medical Policy Panel, December 2017

Medical Policy Group, January 2018 (7): 2018 Updates to Key Points, Key Words, Approved by Governing Bodies, and References; no change to policy statement.

Medical Policy Panel, November 2018

Medical Policy Group, January 2019 (7): Updated Policy Statement- coverage statement added for minimally invasive fusion/stabilization of the sacroiliac joint. Added Keywords: Si Bone, titanium triangular implant. Updated References. Removed Previous Coding section- 0334T was deleted effective 1/1/15. Available for comment February 1, 2019 through March 17, 2019.

Medical Policy Panel, November 2019

Medical Policy Group, December 2019 (7): Updates to Key Points and References; no change to policy statement.                                                                                                                                              

 

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

 

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

  1. The technology must have final approval from the appropriate government regulatory bodies;
  2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;
  3. The technology must improve the net health outcome;
  4. The technology must be as beneficial as any established alternatives;
  5. The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

  1. In accordance with generally accepted standards of medical practice; and
  2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and
  3. Not primarily for the convenience of the patient, physician or other health care provider; and
  4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.