C1737, Joint fusion and fixation device(s), sacroiliac and pelvis, including all
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Document the individual's compliance with the required conservative treatment and other preceding criteria.
- Procedure should be performed only by surgeons with specific training/expertise in minimally invasive SIJ fusion who regularly use image-guidance for implant placement; document surgeon training/experience and use of image guidance.
- Document use of prescription-strength analgesics for several weeks at therapeutic doses as part of conservative therapy.
- Conservative therapy should include NSAIDs, with or without adjuncts (e.g., nerve membrane stabilizers, muscle relaxants); document medication regimen.
Key Coverage Criteria
- Minimally invasive SIJ fixation/fusion with transiliac triangular implant is medically necessary if all criteria are met: pain ≥5/10 impacting life or ADLs; no generalized pain disorders; ≥6 months of prior intensive nonoperative therapy including meds, activity modification, and targeted exercise with home program; nonradicular unilateral SIJ pain localized under L5; Fortin’s point tenderness without other severe tenderness.
- Minimally invasive fixation/fusion of the sacroiliac joint (SIJ) using transiliac placement of a titanium triangular implant (e.g., iFuse) may be considered medically necessary when meeting ALL of the following criteria: Pain >=5, absence of generalized pain behavior, failed 6 months of intensive nonoperative treatment, nonradicular unilateral pain below L5, localization with Fortin’s point tenderness.
- SIJ fixation/fusion with transiliac triangular implant is medically necessary only if all of the listed criteria are met (pain score ≥5; no generalized pain behavior; ≥6 months nonoperative treatment including meds, activity modification, and targeted exercise with home program; nonradicular unilateral pain below L5 over SIJ; Fortin’s point tenderness without other severe tenderness).
- Failure of a minimum 6 months of intensive nonoperative treatment including medication optimization, activity modification, and targeted active therapeutic exercise (lumbar spine, pelvis, SIJ, hip) including a home exercise program.
- Pain is nonradicular, typically unilateral, maximal below L5, localized over the posterior SIJ and consistent with SIJ pain.
- Pain score >= 5/10 that impacts quality of life or limits activities of daily living.
7 Active Policies
BCBSIL-SUR705.033, Minimally Invasive Fixation/Fusion of the Sacroiliac Joint
BCBSMT-SUR705.033, Minimally Invasive Fixation/Fusion of the Sacroiliac Joint
BCBSNM-SUR705.033, Minimally Invasive Fixation/Fusion of the Sacroiliac Joint
BCBSOK-SUR705.033, Minimally Invasive Fixation/Fusion of the Sacroiliac Joint
CARELON-sacroiliac-joint-fusion-2024-10-20-updated-2025-01-01
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.