Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ)
L39812
Minimally invasive sacroiliac joint (SIJ) arthrodesis is covered only when performed WITH placement of a transfixation device; non‑transfixation or device‑less MI arthrodesis and procedures in the presence of infection, tumor, generalized pain disorders (e.g., fibromyalgia), or systemic arthropathies (e.g., ankylosing spondylitis, RA) are excluded. Coverage requires meeting all Sacroiliac Joint Injections and Procedures L39464 criteria (≥75% pain relief from ≥1 diagnostic block and ≥50% relief from ≥1 therapeutic intra‑articular SIJ steroid injection), imaging that excludes destructive lesions/hip or lumbar causes (SIJ radiographs + CT/MRI, AP pelvis, lumbar CT/MRI), documentation of failed conservative therapy, and active participation in a rehabilitation/home‑exercise/functional restoration program.
"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:"