Sacroiliac Joint Fusion or Stabilization - (Effective Date - 2026-10-15) 7.01.93
Minimally invasive sacroiliac joint fusion is medically appropriate only when all listed criteria are met, including lumbopelvic pain originating from the SIJ, at least 75% pain reduction on two separate intra-articular SIJ blocks, pain on three or more of seven provocative tests, and six consecutive months of conservative care that includes NSAIDs, prescription medication optimization, activity modification and supervised physical therapy. The 06/18/26 revision added new provocative physical exam criteria for minimally invasive SIJ fusion and added cotinine testing methods to the nicotine-free status criteria. Open SIJ fusion is medically appropriate only in the listed circumstances, such as post-traumatic SIJ injury, SIJ infection, sacral tumor, multi-segmental spinal deformity fusion, or failed prior percutaneous SIJ fusion.