27278
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
7.66
Facility
$439.22
Non-Facility
$13754.82
Documentation Required
- The patient's medical record must contain documentation that fully supports the medical necessity for services included within LCD L39797, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
- Medical record documentation must be available to Medicare upon request (retain records and make them accessible for audit).
- When a referring/ordering physician is required, include the referring/ordering physician's name and NPI on the claim as part of required documentation.
- For diagnostic testing performed in the course of care, include the test results in the medical record or document the symptoms prompting the test if results are unavailable.
Key Coverage Criteria
- Minimally invasive arthrodesis of the sacroiliac joint is billable when the service meets the coverage and medical necessity criteria in Local Coverage Determination L39797.
- Minimally invasive sacroiliac joint (SIJ) arthrodesis may be billed when the procedure is performed and the patient's condition meets the medical necessity and coverage criteria in Local Coverage Determination L39802.
- Coverage for minimally invasive arthrodesis of the sacroiliac joint (SIJ) is determined by the Local Coverage Determination L39810; follow the clinical indications and medical necessity criteria in LCD L39810.
- Minimally invasive (MI) arthrodesis of the sacroiliac joint (SIJ) with placement of a transfixation device is covered when all other listed criteria are met.
- At least one diagnostic SIJ block demonstrating ≥75% reduction in pain (per the definitions/requirements in policy L39402).
- A trial of at least one therapeutic intra‑articular SIJ corticosteroid injection that produced ≥50% reduction in pain for the expected duration of the injected agent.
19 Active Policies
AMBETTER-CP.MP.126 — Sacroiliac Joint Fusion
A59672 — Billing and Coding: Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ)
A59682 — Billing and Coding: Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ)
A59695 — Billing and Coding: Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ)
L39797 — Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ)
Related Codes
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