Minimally-invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint

Minimally-invasive SI joint fusion is covered for patients with degenerative sacroiliitis or SIJ disruption who have moderate-to-severe, typically unilateral SIJ pain refractory to at least six months of intensive conservative care, localized exam findings (Fortin's point tenderness), a positive cluster of three provocative tests, appropriate imaging excluding alternative pathology, two diagnostic intra-articular anesthetic blocks demonstrating ≥75% pain reduction, and at least one therapeutic SIJ injection. Coverage excludes cases with infection, tumor, fracture, traumatic SIJ instability, inflammatory arthropathy, or generalized pain disorders (e.g., fibromyalgia), and is limited to patients meeting all specified documentation and diagnostic criteria.

"Diagnosis of degenerative sacroiliitis or sacroiliac (SI) joint disruption being treated with MIS-SI joint fusion."