CMM-611: Sacroiliac Joint Fusion or Stabilization

Minimally invasive SI joint fusion/stabilization is covered only when strict diagnostic, imaging, conservative-treatment, implant (device must traverse/transfix the joint) and documentation criteria are met, while procedures lacking required diagnostic confirmation, using implants that do not transfix the joint, same‑day bilateral fusions, joint‑distraction-only procedures, and open fusion for routine mechanical low back or radicular pain are excluded; open fusion is limited to trauma, infection adjuncts, tumor management, multi‑segment long‑fusion constructs, or failed prior percutaneous fusion. Key requirements include two fluoroscopic/CT‑guided diagnostic SI injections with ≥75% pain relief, pelvis and lumbar imaging to exclude other pathology, ≥6 months of conservative care including at least one therapeutic SI injection and supervised PT, specific localized exam findings (Fortin's point tenderness and ≥3 positive provocative tests), exclusion of systemic inflammatory arthropathy and unmanaged major behavioral health/substance issues, and nicotine‑free status confirmed by cotinine ≤10 ng/mL or never‑smoker.