Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A).

The rules say that percutaneous minimally invasive fusion/stabilization of the sacroiliac joint (SIJ fusion) for
the treatment of back pain is a problematic procedure in terms of establishing proven effectiveness and
therefore its medical necessity (given that the underlying mechanisms of chronic back pain are not remedied by
fusion procedures alone, absent obvious acute/subacute trauma). Low back pain is a complex and common
problem in the Medicare population.

The MAC JN has no current LCD given there is a paucity of evidence to establish medical necessity for the
general Medicare population. However, due to the common nature of this problem, the contractor will be
providing access to coverage for CPT code 27279 (Arthrodesis, sacroiliac joint, percutaneous or minimally
invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and
placement of transfixing device). It will be considered for coverage on a case-by-case basis for the treatment of
chronic back pain for certain patients, assuming all other applicable program requirements are met.

According to the Internet Only Manual Publication 100-08, chapter 13, section 13.3 external_pdf.gif, "When
making individual claim determinations, the contractor shall determine whether the item or service in question
is covered based on an LCD or the clinical judgment of the medical reviewer."

The following patient criteria will be considered by First Coast Service Options Inc. (First Coast) medical
reviewers in making clinical judgements if a prepayment or post payment audit is implemented:

1. Patient's report of non-radiating, unilateral pain that is caudal to the lumbar spine (L5 vertebrae), localized
over the posterior SIJ, and consistent with SIJ pain;

2. Patient has undergone and failed a minimum six months of intensive non-operative treatment that must
include medication optimization, activity modification, and active physical therapy;

3. Localized tenderness with palpation of the posterior SIJ in the absence of tenderness of similar severity
elsewhere (e.g., greater trochanter, lumbar spine, coccyx) and other obvious sources for pain do not exist;

4. Positive response to the thigh thrust test OR compression test AND two of the following additional
provocative tests: Gaenslen's test, distraction test, Patrick's sign;

5. Absence of generalized pain behavior (e.g., somatoform disorder) or generalized pain disorders (e.g.,
fibromyalgia);

6. Diagnostic imaging studies that include all of the following:
- Imaging (plain radiographs and a computed tomography (CT) or magnetic resonance imaging (MRI)) of
the SI joint that excludes the presence of destructive lesions (e.g., tumor, infection) or inflammatory
arthropathy that would not be properly addressed by percutaneous SIJ fusion;
- Imaging of the ipsilateral hip (plain radiographs) to rule out osteoarthritis;
- 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;

7. At least 75 percent reduction of pain for the expected duration of the anesthetic used <bimage-guided,
contrast-enhanced SIJ injection on two separate occasions.

After reviewing the available published scientific literature, it is the clinical judgement of the JN MAC that
percutaneous SIJ fusion for SIJ pain is not indicated in the presence of:
- systemic arthropathy such as ankylosing spondylitis or rheumatoid arthritis;
- generalized pain behavior (e.g., somatoform disorder) or generalized pain disorder (e.g., fibromyalgia);
- infection, tumor, or fracture;
- acute, traumatic instability of the SIJ;
- neural compression as seen on an MRI or CT that correlates with the patient's symptoms or other more
likely source for pain.

The procedure code that describes this service is CPT: code 27279 (arthrodesis, sacroiliac joint, percutaneous
or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when
performed, and placement of transfixing device). The JN MAC expects that both of the following ICD-10
codes will be reported for the treatment of chronic low back pain due to sacroiliac joint syndrome: M46.1
(sacroiliitis, not elsewhere classified) and M54.5 (low back pain). </b

You can find this information in the Local Coverage Article: Medical review article for percutaneous
minimally invasive fusion/stabilization of the sacroiliac joint (A55120).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.