CMM-611: Sacroiliac Joint Fusion or Stabilization Guidelines

Covered only when strict criteria are met: minimally invasive SIJ fusion using SI‑BONE iFuse/iFuse‑3D implants and select open SIJ fusion are medically necessary if performed by a trained orthopedic surgeon or neurosurgeon with image guidance and documentation of two contrast‑enhanced fluoroscopic/CT‑guided intra‑articular SIJ blocks each showing ≥75% pain relief, recent (≤6 months) imaging excluding tumor/infection/acute fracture, specified subjective/objective findings (non‑radiating lumbopelvic pain localized to Fortin’s point, localized sacral tenderness, ≥3 positive SIJ provocative tests), ≥6 months of conservative care, exclusion of generalized pain/untreated behavioral health disorders, and nicotine‑free status (cotinine ≤10 ng/mL). Not covered/considered experimental: any procedure not meeting these requirements; percutaneous fusion with generalized pain disorders, infection, tumor, fracture, neural compression, systemic arthropathy, same‑date bilateral percutaneous procedures, use of non‑SI‑BONE implants; and open SIJ fusion for degenerative/mechanical low back or sacroiliac syndrome.