Percutaneous minimally invasive fusion/stabilization of the sacroiliac joint for the treatment of back pain

Percutaneous minimally invasive sacroiliac joint fusion/stabilization is covered for unilateral, non-radiating posterior SIJ pain after failure of at least 6 months of intensive non-operative care, with localized posterior SIJ tenderness, specified positive provocative tests, exclusion of alternative causes by imaging, and reproducible diagnostic relief (>=75%) from image-guided contrast-enhanced SIJ injections on two occasions. Coverage is excluded for systemic inflammatory arthropathies (e.g., ankylosing spondylitis, rheumatoid arthritis), generalized pain disorders (e.g., fibromyalgia), infection, tumor, fracture, acute traumatic SIJ instability, or when neural compression on imaging explains the symptoms.

"Patient has failed a minimum of 6 months of intensive non-operative treatment including medication optimization, activity modification, and active physical therapy."