Prior authorization required when all criteria met

Prior authorization is required for minimally invasive SIJ fusion when the member meets ALL medical appropriateness criteria, including procedure performed for lumbopelvic pain originating from the SIJ, use of structural devices that traverse/transfix the SIJ, diagnostic confirmation with two separate contrast-enhanced fluoroscopic or CT-guided intra-articular SIJ blocks showing ≥75% pain reduction, and prior conservative non-surgical treatment including at least one therapeutic intra-articular SIJ injection unless contraindicated.

• Procedure indication must be lumbopelvic pain originating from the SIJ
• Two separate contrast-enhanced fluoroscopic or CT-guided intra-articular SIJ blocks showing ≥75% pain reduction
• At least one therapeutic intra-articular SIJ injection as part of conservative care

Provide documentation of conservative care, imaging, and eligibility

Prior authorization requests must include documentation that all conservative treatment, diagnostic imaging, and eligibility criteria were met prior to approval for minimally invasive SIJ fusion.

• Detailed record of at least six months of non-invasive treatments (NSAIDs, medication optimization, activity modification, physician-supervised active PT/home exercise)
• Record of therapeutic intra-articular SIJ injection trial

Prior authorization required for open SIJ fusion with full criteria

Open SIJ fusion requires prior authorization and is medically appropriate only when ALL listed criteria are met, including corroborating imaging, documented nicotine-free status, and at least one specified indication (e.g., post‑traumatic SIJ injury, adjunct for infection, sacral tumor management, part of multi‑segmental long fusion, or failed prior percutaneous SIJ fusion).

• Plain X‑rays or CT/MRI showing localized SIJ pathology concordant with history/physical
• Nicotine-free status documented (never-smoker OR ≥6 weeks abstinent with cotinine testing)
• At least one listed indication (post‑traumatic injury, infection adjunct, tumor management, multi‑segmental fusion, or failed prior percutaneous SIJ fusion)

Include CPT/ICD-10, levels, and detailed prior nonsurgical care

Spinal surgery prior authorization must include CPT and ICD-10 codes with levels/motion segments and comprehensive documentation of prior provider‑directed nonsurgical care and responses.

• CPT, ICD‑10, and disc levels/motion segments for planned surgery
• Detailed type, duration, frequency, and response to nonsurgical treatments; explanation if treatments were contraindicated
• Documentation of less than clinically meaningful improvement for each treatment

Authorization requires failed conservative care, positive exams, and injection response

Prior authorization must document ≥6 months of failed conservative care, a positive cluster of at least three provocative SIJ tests, and diagnostic confirmation with ≥75% pain relief on two image‑guided intra‑articular SIJ injections.

• Minimum six months of intensive nonoperative treatment
• At least three positive provocative SIJ maneuvers
• Two separate image‑guided intra‑articular SIJ injections with ≥75% pain reduction documented

Prior authorization tied to listed CPT codes and device context

Prior authorization is required for the CPT codes listed for SIJ arthrodesis/fusion procedures; the policy also references FDA‑cleared SIJ implants when considering device applicability.

• Relevant CPT codes include 27278, 27279, 27280, and 0775T (termed/replaced as noted)
• Policy notes FDA‑cleared implant systems (e.g., SI‑FIX, iFuse, SImmetry, Silex, SI‑LOK)

Follow product coverage rules and applicable CMS LCD

Follow Univera product rules and any applicable CMS LCD (L36406) guidance when requesting prior authorization; medical policy criteria apply only when the member's product covers the service.

• If the member's product does not cover the service, policy criteria do not apply and services may be denied
• When covered by product, follow product‑specific coverage lines (Commercial, Medicaid, Medicare/DSNP) and referenced LCD

Require prior conservative non-surgical treatment and injection trial

A prior conservative, non‑surgical treatment trial is required, including at least one therapeutic intra‑articular SIJ injection unless contraindicated.

• Document reason if injection is contraindicated

Require stepwise conservative care including ≥6 months and injection

Stepwise conservative care must include at least one intra‑articular SIJ injection and a minimum of six consecutive months of non‑invasive therapy before surgical consideration.

• Therapies include NSAIDs, prescription medication optimization, activity modification, and physician‑supervised active physical therapy/home exercise program

Open fusion may follow failed percutaneous SIJ fusion

Open SIJ fusion may be appropriate when a prior percutaneous (minimally invasive) SIJ fusion has failed, supporting a stepwise progression from percutaneous to open fusion in select cases.

• Failure of prior percutaneous SIJ fusion must be documented

Document nicotine‑free status with cotinine testing

Medical record must document nicotine‑free status: either never‑smoker or abstinence from tobacco/nicotine for at least six weeks prior to planned surgery validated by objective cotinine testing (serum, urine, or saliva) within normal range.

• Record type of cotinine test and result (serum, urinary, or saliva) showing abstinence

Provide required plain X‑rays and cross‑sectional imaging

Include diagnostic imaging reports: plain X‑rays (including ipsilateral hip) and cross‑sectional imaging (CT or MRI) that exclude destructive lesions, acute fracture/instability, and evaluate the lumbar spine to exclude alternative pain sources.

• AP pelvis radiograph to evaluate hip pathology
• SIJ CT or MRI to exclude tumor, infection, or autoimmune arthropathy
• Lumbar spine CT or MRI to rule out neural compression or other degenerative conditions

Document conservative treatment history including ≥6 months and injection

Document conservative non‑surgical treatment including at least one therapeutic intra‑articular SIJ injection and at least six consecutive months of non‑invasive treatments (NSAIDs, medication optimization, activity modification, physician‑supervised active PT/home exercise).

• List dates, duration, frequency, and objective response for each conservative therapy
• Include description of supervised/prescribed physical therapy program

Document exclusion of alternative diagnoses (systemic inflammatory arthropathy, hip/lumbar causes)

Provide diagnostic testing to exclude systemic inflammatory arthropathy and documentation demonstrating absence of alternative diagnoses more likely to explain the individual's pain or disability.

• Include relevant lab or imaging studies used to exclude inflammatory arthropathy
• Document rationale excluding alternative diagnoses

Include imaging concordant with exam and nicotine‑free proof for open SIJ fusion

For open SIJ fusion prerequisites, documentation must include imaging demonstrating localized SIJ pathology concordant with history/physical and nicotine‑free status validated by cotinine testing as specified for surgery.

• Imaging concordant with history/physical
• Nicotine abstinence documented with objective cotinine testing

Submit minimum documentation list for prior authorization

Minimum prior authorization documentation for spinal surgery must include CPT and ICD‑10 codes with levels/motion segments, detailed documentation of type/duration/frequency of prior nonsurgical treatments and responses, and explanations if non‑surgical treatment was contraindicated.

• CPT/ICD‑10 codes and planned levels/motion segments
• Detailed nonsurgical treatment history and documented responses

Document behavioral health status and repeat‑procedure timing

Document behavioral health status and provide timing information for repeat procedures where relevant; address absence of unmanaged significant mental or behavioral health disorders.

• If repeat procedure requested, include time frame and rationale

Confirm product coverage before applying policy criteria

Apply the policy criteria only when the member's product covers the service; if the product does not cover the service, requests may be denied and the policy criteria do not apply.

• Verify product coverage (Commercial, Medicaid, Medicare/DSNP) before applying policy criteria

Denial likely without SIJ indication, diagnostic blocks, or positive provocative tests

Denial is likely if the procedure is not performed for lumbopelvic pain originating from the SIJ, if diagnostic confirmation via two separate contrast‑enhanced intra‑articular SIJ blocks does not show ≥75% pain reduction, or if fewer than three provocative SIJ maneuvers elicit typical pain.

• Lack of ≥75% pain reduction on two diagnostic blocks
• Fewer than three positive provocative SIJ maneuvers
• Procedure performed for non‑SIJ lumbopelvic pain

Failure to meet all policy criteria may result in denial

Any case that fails to meet ALL Policy Statement I criteria will be considered not medically appropriate and may be denied.

• Ensure every listed Policy Statement I requirement is documented to avoid denial

Technical or ineligible procedure scenarios risk denial

Procedures in which implant insertion is prevented or bilateral procedures performed on the same date of service are considered not medically appropriate and may be denied.

• Document if implant insertion was not possible and provide rationale
• Bilateral same‑day procedures with titanium triangular implants are excluded

Bilateral same‑day percutaneous SIJ fusion is not appropriate

Minimally invasive/percutaneous SIJ fusion using titanium triangular implants for bilateral procedures on the same date of service is considered not medically appropriate.

• Do not request coverage for bilateral same‑day percutaneous SIJ fusion using titanium triangular implants

Procedures without intent to fuse are not medically necessary

Minimally invasive SIJ fusion or stabilization performed without the intention of fusing the SI joint (joint distraction/non‑fusion) is considered not medically necessary and may be denied.

• Ensure the procedure intent to fuse is explicit in operative documentation

Open SIJ fusion lacking full criteria may be denied

Open SIJ fusion performed without meeting ALL specified open SIJ fusion criteria is considered not medically appropriate and may be denied.

• Document all open SIJ fusion criteria (imaging concordant with exam, nicotine‑free status, and at least one qualifying indication)

Open SIJ fusion investigational indications — denial risk

Open SIJ fusion is considered investigational for mechanical low back pain, sacroiliac joint syndrome, degenerative sacroiliac joint, and radicular pain syndrome; requests for these indications may be denied.

• Do not submit open SIJ fusion requests for the listed investigational indications without documented exceptional justification

Denial triggers: inadequate diagnostic confirmation or insufficient conservative therapy

Lack of required diagnostic confirmation (supportive symptoms, exam findings, imaging excluding other causes, and positive diagnostic injections) or insufficient conservative treatment history may trigger denial.

• Ensure documentation of supportive symptoms, Fortin's point tenderness, and three or more positive provocative tests
• Include pain diary evidence and conservative care timeline

Denial risk if required imaging is missing

Absence of required diagnostic imaging (pelvis AP radiograph, SIJ radiographs plus CT or MRI excluding destructive lesions or autoimmune arthropathy, and lumbar spine CT/MRI to rule out alternate sources) may trigger denial.

• Attach AP pelvis, SIJ CT/MRI, and lumbar spine CT/MRI reports as applicable

Denial risk for missing diagnostic/clinical prerequisites

Absence of at least 75% pain reduction on two separate image‑guided diagnostic intra‑articular SIJ injections, absence of a trial therapeutic intra‑articular SIJ injection, or presence of generalized pain disorders (e.g., fibromyalgia) could lead to noncoverage or denial.

• Two diagnostic injections with documented ≥75% pain reduction are required
• Document therapeutic injection trial and responses
• Document absence of generalized pain disorders

Verify member product coverage to avoid denial

Services may be denied if the member's product does not cover the service; verify product coverage before submitting prior authorization.

• Confirm product coverage (Commercial, Medicaid, Medicare/DSNP) prior to submission