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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 percutaneous minimally invasive fusion/stabilization of the sacroiliac joint (SIJ) for the 
treatment of back pain is indicated for the treatment of SIJ pain for patients with low back/buttock pain who 
meet all of the following criteria: 
a) Have undergone and failed a minimum six months of intensive non-operative treatment that must include 
medication optimization, activity modification, and active physical therapy; 
 
b) Patients 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; 
 
c) 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 their pain do not exist; 
 
d) Positive response to the thigh thrust test OR compression test AND 2 of the following additional provocative 
tests: Gaenslens test, Distraction test, Patricks sign; 
 
e) Absence of generalized pain behavior (e.g. somatoform disorder) or generalized pain disorders (e.g. 
fibromyalgia); 
 
f) Diagnostic imaging studies that include ALL of the following: 
 
1. Imaging (plain radiographs and a CT or 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; 
 
2. Imaging of the ipsilateral hip (plain radiographs) to rule out osteoarthritis; 
 
3. 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; 
 
g) At least 75 percent reduction of pain for the expected duration of the anesthetic used following an image-
guided, contrast-enhanced SIJ injection on two separate occasions. 
 
 You can find this rule in the Local Coverage Determination (LCD) - Percutaneous minimally invasive 
fusion/stabilization of the sacroiliac joint for the treatment of back pain (L36000) - Effective June 30, 2022. 
 
The rules say 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 patients symptoms or other more likely 
source for their pain. 
 
You can find this rule in the Local Coverage Determination (LCD) - Percutaneous minimally invasive 
fusion/stabilization of the sacroiliac joint for the treatment of back pain (L36000) - Effective June 30, 2022. 
 
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.