CurrentHealth-New-EnglandPolicy UM403POL

Sacroiliac Joint Fusion for the Treatment of Adult Low-Back Pain Medical Policy

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This policy governs prior authorization and coverage review for open and minimally invasive sacroiliac joint fusion or stabilization procedures for adults with low-back pain presumed to originate from the sacroiliac joint across Commercial, Medicare Advantage, and Medicaid (BeHealthy) lines of business.

Policy Summary

PayerHealth-New-England

PolicySacroiliac Joint Fusion for the Treatment of Adult Low-Back Pain

Policy CodePolicy UM403POL

Change TypeMaterial revision

Effective DateDecember 1, 2026

Next Review DateN/A

Key ActionApply the adopted InterQual or Medicare criteria appropriate to the procedure and line of business during prior authorization review.

SourceLink

POLICY UPDATE CHANGES

The policy adopted InterQual criteria for minimally invasive, transfixing minimally invasive, and open sacroiliac joint fusion procedures, including separate Medicare criteria for minimally invasive fusion.

Revision of sacroiliac joint stabilization was added to the experimental and investigational services.

The policy definitions were updated to include sacroiliac joint pain-provocation and physical examination tests.

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CurrentHealth-New-EnglandPolicy UM403POL

Sacroiliac Joint Fusion for the Treatment of Adult Low-Back Pain Medical Policy

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Policy Summary

PayerHealth-New-England

PolicySacroiliac Joint Fusion for the Treatment of Adult Low-Back Pain

Policy CodePolicy UM403POL

Change TypeMaterial revision

Effective DateDecember 1, 2026

Next Review DateN/A

Key ActionApply the adopted InterQual or Medicare criteria appropriate to the procedure and line of business during prior authorization review.

SourceLink

POLICY UPDATE CHANGES

Revision of sacroiliac joint stabilization was added to the experimental and investigational services.

The policy definitions were updated to include sacroiliac joint pain-provocation and physical examination tests.

Applicable lines of business

3Procedure codes addressed

2Codes requiring prior authorization

2Experimental or investigational categories

2-4Typical iFuse implants

Medical Necessity and Exclusions

Adopted criteria by procedure and line of business

Covered services are subject to the applicable adopted InterQual or Medicare criteria.

Commercial and Medicaid minimally invasive procedures: Minimally invasive sacroiliac joint fusion/arthrodesis and transfixing minimally invasive sacroiliac joint fusion use InterQual CP: Procedures, Sacroiliac (SI) Joint Fusion, Minimally Invasive Sacroiliac (SI) Joint Fusion.

Applies to Commercial and Medicaid lines of business.

Medicare minimally invasive procedures: Medicare minimally invasive sacroiliac joint fusion uses Medicare: Procedures, Minimally invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint NGS, Sacroiliac Joint Fusion, Minimally Invasive criteria.

The Medicare criteria refer to LCD L36406, Minimally invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint.

Open procedures: Open sacroiliac joint fusion/arthrodesis uses CP: Procedures, Sacroiliac (SI) Joint Fusion, Open Sacroiliac (SI) Joint Fusion criteria.

Applies to Commercial, Medicare Advantage, and Medicaid lines of business.

Experimental and investigational

The following services are not covered as medically necessary under this policy because they are experimental and investigational.

Experimental and investigational services: Fusion or stabilization of the sacroiliac joint for treatment of back pain presumed to originate from the sacroiliac joint is experimental and investigational under all other conditions and with any other devices not listed in the policy.

Revision of sacroiliac joint stabilization is also experimental and investigational.

Sacroiliac joint fusion or stabilization for back pain presumed to originate from the sacroiliac joint is considered experimental and investigational when performed under conditions or with devices not listed in the policy. These services are excluded from coverage under this policy.

Revision of sacroiliac joint stabilization is considered experimental and investigational and is excluded from coverage under this policy.

Procedure Codes and Authorization Status

Experimental/InvestigationalCPTExperimental

27278

Arthrodesis, sacroiliac joint, percutaneous, with image guidance, including placement of intra-articular implant(s) (eg, bone allograft[s], synthetic device[s]), without placement of transfixation device.

Procedure codes with prior authorizationCPT

27279	Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization) with image guidance, includes obtaining bone graft when performed, and placement of transfixing device.
27280	Arthrodesis, open sacroiliac joint, including obtaining bone graft, including instrumentation, when performed.

Authorization and Documentation Requirements

Billing Rule

Apply Line-of-Business Criteria

Apply the applicable Health New England-adopted criteria for the member’s line of business and procedure. Commercial and Medicaid requests for minimally invasive or transfixing SI joint fusion use the applicable InterQual criteria; Medicare requests use the adopted Medicare/NGS criteria, and open SI joint fusion uses the adopted InterQual criteria for all lines of business.

Commercial and Medicaid — minimally invasive or transfixing SI joint fusion: InterQual CP: Procedures, Sacroiliac (SI) Joint Fusion, Minimally Invasive Sacroiliac (SI) Joint Fusion.
Medicare — minimally invasive SI joint fusion: Medicare: Procedures, Minimally invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint NGS, Sacroiliac Joint Fusion, Minimally Invasive; criteria refer to LCD L36406.
Open SI joint fusion — all lines of business: InterQual CP: Procedures, Sacroiliac (SI) Joint Fusion, Open Sacroiliac (SI) Joint Fusion.
MassHealth: No MassHealth guidelines are identified for SI joint fusion for treatment of adult low-back pain. Providers may obtain InterQual SmartSheets through the HNE provider portal or by calling (413) 787-4004.

Procedure Overview

Sacroiliac joint fusion stabilizes the joint by fusing the iliac crest and sacrum, typically after cartilage removal and bone grafting. Open procedures may use plates, screws, or an interbody fusion cage. Minimally invasive fusion may use triangular titanium implants placed across the joint with image guidance. The policy addresses adults with sacroiliac joint dysfunction or chronic sacroiliac joint pain who have not obtained adequate relief from nonsurgical management; medical-necessity requirements are determined under the applicable adopted criteria.

Clinical Examination Tests

Thigh Thrust Test

PositionPatient lies supine with the tested-side hip flexed to approximately 90°.

TechniqueThe examiner applies an anteroposterior shear force to the sacroiliac joint through the axis of the femur.

Positive findingReproduction of pain indicates a positive test.

Long Dorsal Ligament Test

TechniqueThe examiner palpates the dorsal ligament.

Positive findingPain with palpation of the dorsal ligament is a positive finding.

Purpose

Policy Summary

PayerHealth-New-England

PolicySacroiliac Joint Fusion for the Treatment of Adult Low-Back Pain

Policy CodePolicy UM403POL

Change TypeMaterial revision

Effective DateDecember 1, 2026

Next Review DateN/A

Key ActionApply the adopted InterQual or Medicare criteria appropriate to the procedure and line of business during prior authorization review.

SourceLink

On This Page

Prior Authorization

Prior Authorization Required

Obtain prior authorization before performing the applicable SI joint fusion procedures. CPT 27279 and CPT 27280 require prior authorization; code inclusion does not guarantee coverage or payment under the member’s benefit plan.

CPT 27279: Percutaneous or minimally invasive SI joint arthrodesis with image guidance and transfixing device — prior authorization required.
CPT 27280: Open SI joint arthrodesis — prior authorization required.

Unsupported block type: documentation切

Note

Qualified Surgeon and Image Guidance

This technically demanding procedure should be performed only by a surgeon with specific training and expertise in minimally invasive SI joint fusion for chronic sacroiliac joint pain. The surgeon should regularly use image guidance for implant placement.

Qualified surgeon: specific training and expertise in minimally invasive SI joint fusion surgery.
Technique: regular use of image guidance for implant placement.

Denial Risk

Unlisted Conditions or Devices

SI joint fusion or stabilization for back pain presumed to originate from the SI joint is experimental and investigational under conditions or with devices not listed in the policy. Such requests may be denied.

Unlisted conditions are experimental and investigational.
Devices not listed in the policy are experimental and investigational.

Denial Risk

Revision Stabilization

Revision of SI joint stabilization is considered experimental and investigational and may be denied.

Applies to revision SI joint stabilization procedures.

Documentation Required

Insufficient Clinical Documentation

Include sufficient clinical documentation for Health New England to properly review the prior authorization request. Without the required documentation and information, Health New England cannot properly determine whether the patient meets the applicable criteria, and the request may be denied or remain unreviewable.

Provide documentation supporting the patient’s diagnosis, relevant clinical findings, and medical necessity under the applicable line-of-business criteria.
Missing or insufficient clinical evidence creates a denial risk and prevents proper prior authorization review.

The test assesses for pain arising from the dorsal ligament.

Compression Test

Test typePain-provocation test, also called the Approximation Test.

Structures stressedThe test stresses sacroiliac joint structures, particularly the posterior sacroiliac ligament.

PurposeThe maneuver attempts to reproduce the patient’s symptoms.

Gaenslen Sign

PositioningThe pelvis is fixed by flexion of the opposite hip.

ManeuverThe tested hip is hyperextended.

Associated findingThe maneuver produces torsional stress at the sacroiliac and lumbosacral joints; pain indicates a positive finding.

FABER/Patrick Test

PositioningThe patient is supine with the hip and knee flexed; the external malleolus is placed above the patella of the opposite leg.

ManeuverThe knee is depressed.

Associated findingPain elicited by depressing the knee indicates sacroiliac disease.