Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ)

Jurisdiction: J15 MAC Part B. States: Kentucky, Ohio. Type: Active LCD

Covered Indications Minimally Invasive (MI) Arthrodesis of the sacroiliac joint (SIJ) WITH placement of a transfixation device is considered medically reasonable and necessary when ALL of the following criteria are met: Patient must meet all requirements for coverage as outlined in Sacroiliac Joint Injections and Procedures L39383 including: At least 1 diagnostic block with ≥75% reduction of pain as defined in L39383 AND A trial of at least 1 therapeutic intra-articular SIJ injection (i.e., corticosteroid injection that results in a ≥50% reduction of pain for the expected duration of the injected agent AND Diagnostic imaging studies that include ALL the following: Imaging (plain radiographs and a computed tomography (CT) or magnetic resonance imaging (MRI)) of the SIJ that excludes the presence of destructive lesions (e.g., tumor, infection), fracture, traumatic SIJ instability, or inflammatory arthropathy that would not be properly addressed by percutaneous SIJ fusion (SIJF) Imaging of the pelvis (anteroposterior (AP) plain radiograph) to rule out concomitant hip pathology 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 MI Arthrodesis of the SIJ WITHOUT placement of a transfixation device is NOT considered medically reasonable and necessary. Limitations: Absence of generalized pain behavior (e.g., somatoform disorder) or generalized pain disorders (e.g., fibromyalgia) Patient should be part of an ongoing care plan, and be actively participating in a rehabilitation program, home exercise program or functional restoration program