0775T — Fusion of sacroiliac joint between spine and pelvis with bone graft, accessed through skin using imaging guidance
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documentation of failure of at least six consecutive months of conservative treatment (records of therapies and duration)
- Clinical documentation supporting diagnosis of low back and/or buttock pain attributed to the sacroiliac joint and rationale for SIJ fusion
- Documentation that medication optimization was attempted or is contraindicated.
- Documentation of activity modification recommendations and patient adherence as applicable.
Key Coverage Criteria
- Stabilization of a traumatic, severe disruption, or fracture of the pelvic ring
- As an adjunct to sacrectomy or partial sacrectomy for treatment of sacral tumors
- As an adjunct to medical treatment of sacroiliac joint infection or sepsis (e.g., osteomyelitis, pyogenic sacroiliitis)
- During multi-segment spinal constructs (e.g., correction of spinal deformity in scoliosis or kyphosis surgery extending to the ilium)
- Minimally invasive SIJ fusion for treatment of low back/buttock pain when all policy criteria are met, including failure of at least six consecutive months of conservative treatment
- Medication optimization for the condition unless contraindicated.
1 Active Policy
AMBETTER-CP.MP.126 — Sacroiliac Joint Fusion
Related Codes
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