Minimally Invasive Fixation/Fusion of the Sacroiliac Joint

This policy covers minimally invasive transiliac fixation/fusion of the sacroiliac joint using a titanium triangular implant (e.g., iFuse) for chronic SIJ pain when the policy's specific medical necessity criteria are met. Coverage is limited to patients with localized, typically unilateral nonradicular SIJ pain (≥5/10 affecting function) who have failed conservative care (including ≥6 months of medical management and ≥6 weeks of active physical therapy), have diagnostic image‑guided SIJ injections and ≥3 positive provocative SIJ tests consistent with SIJ pain, and whose procedure is performed by specifically trained surgeons using image guidance; SIJ fusion for infection, trauma, neoplasm, or with devices not listed in the policy is investigational.

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