27280
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
19.50
Facility
$1283.60
Non-Facility
$1283.60
Documentation Required
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage; refer to the protocol titled Medical Records Documentation Used for Reviews.
- For minimally invasive SIJ fusion (Titanium Triangular Implant System), documentation that the patient has "undergone and failed a minimum 6 months of intensive nonoperative treatment" including medication optimization (unless contraindicated), activity modification, and active therapeutic exercise targeted at the lumbar spine, pelvis, SIJ, and hip.
- Documentation of the patient's reported pain: "nonradicular, typically, unilateral pain that is maximal below the L5 vertebrae, localized over the posterior SIJ, and consistent with SIJ pain."
- Documentation of physical examination findings: localized tenderness with palpation over the sacral sulcus (Fortin's point) or documentation that tenderness elsewhere would not explain the symptoms.
Key Coverage Criteria
- Sacroiliac Joint (SI) injections are proven and medically necessary in certain circumstances. For medical necessity clinical coverage criteria, refer to the InterQual® CP: Procedures, Sacroiliac (SI) Joint Injection.
- Open Sacroiliac Joint Fusion is proven and medically necessary for treating the following indications: Stabilization of a traumatic, severe disruption, or fracture of the pelvic ring.
- Open Sacroiliac Joint Fusion is proven and medically necessary for treating the following indications: Management of sacral tumor (e.g., sacrectomy or partial sacrectomy related to tumors involving the sacrum).
- Open Sacroiliac Joint Fusion is proven and medically necessary for treating the following indications: As an adjunctive to medical treatment for Sacroiliac Joint infection or sepsis.
- Open Sacroiliac Joint Fusion is proven and medically necessary for treating the following indications: When performed as part of multisegmental spinal constructs for the correction of spinal deformity (e.g., idiopathic scoliosis, neuromuscular scoliosis).
- Minimally invasive joint fusion for degenerative sacroiliac disease using a Titanium Triangular Implant System is proven and medically necessary when ALL of the following criteria are met: "Have undergone and failed a minimum 6 months of intensive nonoperative treatment that includes all of the following: medication optimization (unless contraindicated); activity modification; active therapeutic exercise targeted at the lumbar spine, pelvis, Sacroiliac Joint (SIJ), and hip."
13 Active Policies
AMBETTER-CP.MP.126 — Sacroiliac Joint Fusion
SUR712.036 — Lumbar Spinal Fusion
CARELON-sacroiliac-joint-fusion-2024-10-20-updated-2025-01-01 — Sacroiliac Joint Fusion
UHC-POL-sacroiliac-joint-interventions — Sacroiliac Joint Interventions
UMR-POL-UMR-sacroiliac-joint-interventions — Sacroiliac Joint Interventions
Related Codes
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