Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ)

Minimally invasive sacroiliac joint arthrodesis with placement of a transfixation device is covered only when all criteria are met, including a diagnostic SIJ block with ≥75% pain reduction, a therapeutic intra-articular steroid injection with ≥50% pain reduction, and imaging (SIJ, pelvis AP, lumbar spine) excluding alternative causes. Procedures performed without a transfixation device, patients with generalized pain disorders (e.g., fibromyalgia or somatoform disorder), or patients not actively participating in a rehabilitation/ongoing care plan are excluded from coverage.

"Minimally invasive arthrodesis (MI SIJ fusion) of the sacroiliac joint with placement of a transfixation device is medically reasonable and necessary when all other listed criteria are met."

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