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 services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say that 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: 
o Imaging (plain radiographs and a CT or 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 
o Imaging of the pelvis (AP plain radiograph) to rule out concomitant hip pathology 
o 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 this rule in 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.