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). 
 
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. The rules say 
Minimally invasive surgical (MIS) fusion of the sacroiliac joint (SIJ) utilizing a lateral transfixation approach is 
considered medically necessary when ALL of the following criteria are met: Have moderate to severe pain with 
functional impairment and pain that persists, despite a minimum 6 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 (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 SIJ 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 (SIJF), imaging of 
the pelvis (anteroposterior (AP) plain radiograph) 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% reduction of pain for the expected duration of 2 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, and a trial of at least 1 therapeutic intra-articular 
SIJ injection (i.e., corticosteroid injection. You can find this information in Medicares Local Coverage 
Determination  Minimally Invasive Surgical MIS Fusion of the Sacroiliac Joint (SIJ) L39025.