CMM-611: Sacroiliac Joint Fusion or Stabilization

Covered: minimally invasive SIJ fusion using SI‑BONE iFuse/iFuse‑3D implants and select open SIJ fusion when strict criteria are met; excluded/considered experimental are non‑SI‑BONE implants, bilateral same‑day procedures, systemic arthropathy, infection/tumor/fracture, acute traumatic instability, generalized pain disorders, and any cases not meeting the policy criteria. Key requirements: documented Fortin’s point and localized SIJ pain with ≥3 positive SIJ provocative tests, ≥75% pain relief from two contrast‑enhanced image‑guided intra‑articular SIJ blocks, ≥6 months of conservative care (unless contraindicated), recent imaging, surgeon training with image guidance, documented nicotine‑free status and exclusion of alternative/systemic causes and unmanaged significant behavioral/mental health disorders.

"Minimally invasive or percutaneous SIJ fusion or stabilization is EIU for systemic arthropathy (e."