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

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.