Anthem Blue Cross Connecticut CG-SURG-111 Open Sacroiliac Joint Fusion Form
This procedure is not covered
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:
- 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/sepsis; or
- Severe traumatic injuries associated with pelvic ring disruption (that is, fracture or dislocation); or
- 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.
Ask this policy anything