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 studies have reported the source of chronic lower back, buttock, groin, or lower extremity 
pain is from disorders of the sacroiliac (SI) joint in 10% to 26% of cases. Nevertheless, sacroiliac joint 
dysfunction is a controversial topic as there is no single clinical, imaging, or provocative test that definitively 
confirms the SI joint as a primary source of pain. In addition, the SI joint may be a referred site of pain, 
including from a degenerative disc at L5-S1, spinal stenosis, or osteoarthritis of the hip. 
 
SI joint pathology may include degenerative and inflammatory arthritis, post-traumatic arthritis, post-partum 
instability, post-infectious arthritis, joint degeneration related to previous lumbar spinal fusion, joint damage 
from previous posterior iliac crest bone graft harvesting, and neoplastic processes. This policy is directed at 
minimally invasive surgical (MIS) fusion of the sacroiliac (SI) joint for treatment of degenerative sacroiliitis or 
sacroiliac disruption. 
 
Traditionally, treatment begins with conservative management (e.g., physical therapy, activity modification and 
analgesic medication). Open SI joint fusion has long been another option, albeit sparingly used given the 
significant morbidity associated with the depth and anatomic location of the SI joint. Recent survey data show 
MIS-SI joint fusion displacing open SI joint fusion. MIS-SI joint fusion involves percutaneous insertion of a 
metallic device across the sacroiliac joint (SIJ) that is intended to fuse the joint rather than just stabilize the 
joint as with simple of insertion of screws. Smith reported a retrospective multi-center comparison of MIS-SI 
joint fusion with open SI joint fusion in 114 and 149 patients, respectively, with MIS-SI joint fusion 
demonstrating statistically positive outcomes. Though both groups seemed to improve, there was reportedly an 
average of 3.5 points less pain in the percutaneous group. 
 
Indications of Coverage 
 
Minimally-invasive surgical (MIS) fusion of the sacroiliac (SI) joint is considered medically necessary when 
ALL of the following criteria are met: 
 
Have moderate to severe pain with functional impairment and pain persists despite a minimum six months of 
intensive nonoperative treatment that must include medication optimization, activity modification, bracing, and active therapeutic exercise targeted at the lumbar spine, pelvis, SIJ and hip including a home exercise program 
Patients report of typically unilateral pain that is caudal to the lumbar spine (L5 vertebrae), localized over the 
posterior SIJ, and consistent with SIJ pain 
A thorough physical examination demonstrating localized tenderness with palpation over the sacral sulcus 
(Fortins point, i.e. at the insertion of the long dorsal ligament inferior to the posterior superior iliac spine or 
PSIS) in the absence of tenderness of similar severity elsewhere (e.g. greater trochanter, lumbar spine, coccyx) 
and that other obvious sources for their pain do not exist 
Positive response to a cluster of 3 provocative tests (e.g. thigh thrust test, compression test, Gaenslens test, 
distraction test, Patricks sign, posterior provocation test). 
Absence of generalized pain behavior (e.g. somatoform disorder) or generalized pain disorders (e.g. 
fibromyalgia) 
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), fracture, traumatic SIJ instability, 
or inflammatory arthropathy that would not be properly addressed by percutaneous SIJ fusion 
Imaging of the pelvis to rule out concomitant hip pathology 
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 
At least 75 percent reduction of pain for the expected duration of two anesthetics (on separate visits each with a 
different duration of action), and the ability to perform previously painful maneuvers, following an image-
guided, contrast-enhanced intra-articular SIJ injection. 
A trial of at least one therapeutic intra-articular SIJ injection (i.e. corticosteroid injection) 
 
You can find these rules in the Local Coverage Determination (LCD) Minimally invasive Surgical (MIS) 
Fusion of the Sacroiliac (SI) Joint L36406. 
 
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.