27279
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
11.83
Facility
$758.53
Non-Facility
$758.53
Documentation Required
- The patient's medical record must contain documentation that fully supports medical necessity for services included within the related LCD, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
- Medical record documentation must be available to Medicare upon request.
- All documentation must be maintained in the patient's medical record and be made available to the contractor upon request.
- Every page of the medical record must be legible and include appropriate patient identification information such as complete name and dates of service.
Key Coverage Criteria
- Minimally-invasive surgical fusion of the sacroiliac (SI) joint is covered when the patient's medical record documents medical necessity per the related Local Coverage Determination (LCD), including relevant history, physical exam, and diagnostic test results supporting the procedure.
- Coverage for percutaneous minimally invasive fusion/stabilization of the sacroiliac joint is determined by the related Local Coverage Determination L36000 and only covered when that LCD's clinical indications are met.
- Patient has failed a minimum of 6 months of intensive non-operative treatment including medication optimization, activity modification, and active physical therapy.
- Patient reports non-radiating, unilateral pain caudal to the lumbar spine (below vertebra L5), localized over the posterior sacroiliac joint and consistent with SIJ pain.
- Localized tenderness to palpation of the posterior sacroiliac joint in the absence of tenderness of similar severity elsewhere (e.g., greater trochanter, lumbar spine, coccyx) and no other obvious pain source.
- Positive response to the thigh thrust test OR compression test AND positive results on at least two of the following provocative tests: Gaenslen's test, Distraction test, Patrick's sign.
20 Active Policies
L36000 — Percutaneous minimally invasive fusion/stabilization of the sacroiliac joint for the treatment of back pain
J05
A57596 — Billing and Coding: Percutaneous minimally invasive fusion/stabilization of the sacroiliac joint for the treatment of back pain
J05
A57431 — Billing and Coding: Minimally-invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint
J06
L36406 — Minimally-invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint
J06
Related Codes
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