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Anthem Blue Cross ConnecticutCommercial Clinical Policy

Anthem Blue Cross Connecticut CG-SURG-111 Open Sacroiliac Joint Fusion Form


Open Sacroiliac Joint Fusion

Indications

(692971) Is the open sacroiliac joint fusion being performed as an adjunct to sacrectomy or partial sacrectomy related to tumors involving the sacrum? 
(692972) Is the open sacroiliac joint fusion being performed as an adjunct to the medical treatment of sacroiliac joint infection/sepsis? 
(692973) Is the procedure for severe traumatic injuries associated with pelvic ring disruption (e.g., fracture or dislocation)? 
(692974) Is the procedure part of a multisegment spinal construct extending to the ilium, such as for correction of deformity in scoliosis or kyphosis surgery? 

Contraindications

(692975) Is the open sacroiliac joint fusion being performed for conditions not listed above, including but not limited to poorly defined low back pain or sacral insufficiency fractures? 
Effective Date

06/28/2023

Last Reviewed

05/11/2023

Original Document

  Reference



This document addresses proposed indications for open sacroiliac joint fusion, a surgical procedure that fuses the iliac bone (pelvis) to the spine (sacrum). It is performed for a variety of orthopedic conditions including trauma (with fracture), infection, cancer, and spinal instability.

Note: This document does not address minimally invasive sacroiliac joint fusion procedures.

Clinical Indications

Medically Necessary:

Open sacroiliac joint fusion procedures are considered medically necessary for any of the following indications:

  1. As an adjunct to sacrectomy or partial sacrectomy related to tumors involving the sacrum; or
  2. As an adjunct to the medical treatment of sacroiliac joint infection/sepsis; or
  3. Severe traumatic injuries associated with pelvic ring disruption (that is, fracture or dislocation); or
  4. During multisegment spinal constructs (for example, correction of deformity in scoliosis or kyphosis surgery) extending to the ilium.

Not Medically Necessary:

Open sacroiliac joint fusion procedures for conditions not listed above, including but not limited to, poorly defined low back pain and sacral insufficiency fractures are considered not medically necessary.