Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ)
L39809
MI sacroiliac joint arthrodesis WITH placement of a transfixation device is covered as medically necessary; MI approaches that do not transfix the SIJ (distraction-only, posterior/non-transfixation, or other experimental techniques) and procedures for other lumbar causes (e.g., radiculopathy, infection, tumor, fracture, pseudoarthrosis, spinal instrumentation) are excluded. Coverage requires ≥6 months of SIJ‑predominant LBP refractory to conservative care, diagnostic imaging (SIJ x‑ray + CT/MRI, AP pelvis, lumbar CT/MRI) excluding other causes, ≥3 positive provocative SIJ tests, one therapeutic intra‑articular steroid injection with ≥50% pain relief, two image‑guided contrast‑enhanced diagnostic intra‑articular anesthetic injections each with ≥75% relief for the expected duration, consistent pain‑scale documentation pre/post procedures, and operative/device documentation showing transfixation.
"Minimally Invasive (MI) Arthrodesis of the sacroiliac joint (SIJ) WITH placement of a transfixation device is considered medically reasonable and necessary when ALL of the following criteria are met:"