Sacroiliac Joint Fusion for the Treatment of Adult Low-Back Pain Form

1

Sacroiliac Joint Fusion for the Treatment of Adult Low-Back Pain Medical Policy
Revision Effective: September 1, 2025 Policy Number:

UM403POL

Approval Date: 6/24/2025

Line(s) of Business:

Commercial
Medicare Advantage
Medicaid (BeHealthy)

Description

Open Sacroiliac Joint (SIJ) fusion typically involves opening the SIJ, denuding of cartilage, and bone grafting. To stabilize the SIJ, the iliac crest bone and the sacrum are typically held together by plates or screws or an interbody fusion cage until the 2 bones fuse.

The use of minimally invasive sacroiliac joint (SIJ) fusion with the iFuse Implant System (SI-Bone Inc.) for the treatment of adults with SIJ dysfunction, who have not experienced adequate relief from nonsurgical management (NSM) system, consists of sterile, rigid, titanium rods that have a triangular cross-section to minimize rotation and maximize surface area of the SIJ. These implants are coated with a porous titanium plasma spray to facilitate biologic fixation to bone. A series of 2 to 4 implants is placed in a lateral-to-medial direction across the SIJ via a minimally invasive surgical procedure.

 Line of Business

Commercial:
Refer to criteria under the Policy section in this medical policy.

Medicaid – BeHealthy:
Refer to criteria under the Policy section in this medical policy. There are no MassHealth guidelines for Sacroiliac joint fusion for the treatment of adult low back pain.

Medicare:
Health New England follows Local Coverage Determination (LCD) L36406, Minimally invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint.

2

Policy

I. Medically Necessary:

A. Minimally invasive fusion/stabilization of the sacroiliac joint using a titanium triangular implant (iFuse Implant System) may be considered medically necessary when ALL of the following criteria are met (for all lines of business except Medicare - link below):

1. Adults 18 years old or greater with SI joint pain for greater than 6 months (or greater than 18 months for pregnancy-induced pelvic girdle pain); AND

2. Pain is at least 5 on a 0-to-10 rating scale that impacts quality of life or limits activities of daily living; AND

3. Absence of generalized pain behavior (e.g., somatoform disorder) or generalized pain disorders (e.g., fibromyalgia); AND

4. Patients have undergone and failed a minimum 6 months of intensive non-operative 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

5. Pain is caudal to the lumbar spine (L5 vertebra), localized over the posterior sacroiliac joint, is non- radiating lumbar/pelvic pain without radiation to hip, groin or radiating to legs and consistent with sacroiliac joint pain; AND

6. 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

7. Positive response from at least THREE (3) of the following provocative tests:  Long ligament test  Faber’s test/Patrick’s sign  Active straight leg raise  Compression test  Distraction test  Thigh thrust test (not recommended for those who are pregnant or those with connective tissue disorder)  Gaenslen’s test; AND

8. Member is a nonsmoker, or is documented to refrain from use of tobacco products for at least 6 weeks prior to the planned surgery; AND

9. 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

10. A trial of a therapeutic sacroiliac joint injection (i.e., corticosteroid injection) has been performed at least once; AND

3

11. Clinical documentation notes that pain interferes with activities of daily living (ADL’S); AND

12. Diagnostic imaging studies include ALL of the following:

    a. 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

    b. Imaging of the pelvis (anteroposterior plain radiograph) rules out concomitant hip pathology; AND

    c. 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

    d. Imaging of the sacroiliac joint indicates evidence of injury and/or degeneration.

    B. Criteria for minimally invasive surgical (MIS) fusion of the sacroiliac (SI) joint (L36406) for Medicare line of business can be accessed at CMS website using the link below.

    https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=36406

    C. Open sacroiliac joint fusion [fuses iliac bone (pelvis) to the spine (sacrum)] procedures may be
    considered medically necessary for any of the following indications for all lines of business:

13. As an adjunct to sacrectomy or partial sacrectomy, related to tumors (chordoma) involving the sacrum, OR

14. As an adjunct to the medical treatment of sacroiliac joint infection/sepsis; OR

15. Severe traumatic injuries associated with pelvic ring disruption (that is, fracture or dislocation); OR

16. During multi-segment spinal constructs (for example, correction of deformity in scoliosis or kyphosis surgery) extending to the ilium.

    Note:

    • This technically demanding procedure should only be done by surgeons who have specific training and expertise in minimally invasive sacroiliac joint fusion surgery for chronic sacroiliac joint pain and who regularly use image-guidance for implant placement.

    II. Experimental and Investigational:

    • Fusion/stabilization of the sacroiliac joint for the treatment of back pain presumed to originate from the sacroiliac joint is considered investigational under all other conditions and with any other devices not listed above. • Revision of SI joint stabilization is considered experimental and investigational.

4

Policy Guidelines and Definitions

• Sacrectomy: Excision or resection of the sacrum to facilitate an operation for pelvic tumor resection.

• Chordoma: Rare type of cancerous tumor that can occur anywhere in the spine. From the base of the skull to tail bone. Slowly growing tumor that gradually extends into bone and soft tissue.

• Thigh Thrust test: Thigh Thrust Test (Posterior Shear Test) With the thigh thrust test, the patient lay in a supine position while the tested-side hip joint was flexed to approximately 90° by the examiner. An anteroposterior shear force was applied to the SIJ through the axis of the femur. The resulting pain indicated the test was positive.

• Long dorsal ligament test: Pain with palpation of dorsal ligament

• Compression test: The Sacroiliac Joint (SIJ) Compression Test or “Approximation Test” is a pain provocation test which stresses the SIJ structures, in particular, the posterior SIJ ligament, to attempt to replicate patient's symptoms.

• Gaenslen Sign: Pain on hyperextension of the hip with pelvis fixed by flexion of opposite hip. Causes a torsion stress at the sacroiliac and lumbosacral joints.

• Fabers/Patrick Test: Test that determines the presence of sacroiliac disease. Member is in supine position with hip and knee flexed with external malleolus placed above the patella of the opposite leg. Upon depressing the knee, pain is elicited in sacroiliac disease.

Coding Guidance

Code
Description
PA 27278 Arthrodesis, sacroiliac joint, percutaneous, with image guidance, including placement of intra-articular implant(s) (eg, bone allograft[s], synthetic device[s]), without placement of transfixation device Experimental/ Investigational 27279

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

Yes 27280 Arthrodesis, open sacroiliac joint, including obtaining bone graft, including instrumentation, when performed
Yes

CPT® Copyright 2025 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Note: CPT/HCPCS codes are included for informational purposes and may not be all inclusive. Inclusion or exclusion of a CPT/HCPCS code(s) does not signify or imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member’s specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee of payment. Other policies and coverage determination guidelines may apply.

References

5

Foley, B., & Buschbacher, R. (2006, December). Sacroiliac joint pain: Anatomy, biomechanics, diagnosis, and treatment

https://www.ncbi.nlm.nih.gov/pubmed/17117004

Rudolph, L. (2012, November 30). Sacroiliac Joint Arthrodesis-MIS Technique with Titanium Implants: Report of the First 50 Patients and Outcomes

https://www.ncbi.nlm.nih.gov/pubmed/23284593

Sachs, D., Capobianco, R., Cher, D., Holt, T., Gundanna, M., Graven, T., … Cummings, Jr., J. (2014, August 28). One-year outcomes after minimally invasive sacroiliac joint fusion with a series of triangular implants: A multicenter, patient-level analysis

https://www.ncbi.nlm.nih.gov/pubmed/25210479

Local Coverage Determination (LCD): Minimally-invasive Surgical (MIS) fusion of the sacroiliac (SI) joint (L36406)
Revision effective date 10/10/2019

ttps://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=36406

Yeomans, DC, S. G. (2018, February 7). Surgical Treatment for Sacroiliac Joint Pain

https://www.spine-health.com/conditions/sacroiliac-joint-dysfunction/surgical-treatment-sacroiliac-joint- pain

Kutz, MD, S. (2017, December 21). What to Know About Sacroiliac Joint Fusion

https://www.spine-health.com/treatment/spinal-fusion/what-know-about-sacroiliac-joint-fusion

SPINE-health

Cross, W. W., Delbridge, A., Hales, D., & Fielding, L. C. (2018, January 17). Minimally Invasive Sacroiliac Joint Fusion: 2-Year Radiographic and Clinical Outcomes with a Principles-Based SIJ Fusion System https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5791206/

Marshall, S. (2018, May 25). Why sacroiliac joint fusion surgery is still a puddle of dreams.

https://spinalnewsinternational.com/sacroiliac-joint-fusion-surgery/

Wheeler, T. (2019, December 8). Do I Need Surgery for SI Joint Pain

https://www.webmd.com/back-pain/si-joint-dysfunction-surgery

Minimally Invasive Sacroiliac Joint Fusion Using Triangular Titanium Implants (iFuse Implant System, SI-Bone Inc.)

https://evidence.hayesinc.com/report/dir.infuse3000

iFuse Implant System

https://si-bone.com/si-joint-pain-treatment/ifuse-implant-system

SI-BONE, SI University: SI joint and iFuse

SI University: SI Joint and iFuse Training | SI-BONE

6

Policy Implementation

Approved by the Medical and Pharmacy Policy Committee

Kate McIntosh MD MBA

Chief Medical Officer

Saad Usmani MD MBA

Medical Director

Date Update 1/31/2012 Initial Effective Date 03/2022 CPT codes 27280 is now covered under Mass Health/Medicaid 02/2023 Updated policy language. 1/2024 Added Line of Business section 5/2024 Criteria in A7 clarified. Added definitions. 5/2025 Added revision of SI joint stabilization to Experimental/Investigational section.

Medical Criteria Disclaimer

Property of Health New England. All rights reserved. The treating physician or primary care provider must submit to Health New England the clinical evidence that the patient meets the criteria for the treatment, testing or surgical procedure. Without this documentation and information, Health New England will not be able to properly review the request for prior authorization. The clinical review criteria reflect how Health New England determines whether certain services or supplies are medically necessary. Health New England established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). Health New England expressly reserves the right to revise these conclusions as clinical information changes and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by Health New England, as some programs exclude coverage for services or supplies that Health New England considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government, or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.