Skip to main content
HealthPartners

Coverage criteria policies

Sacroiliac joint pain treatment procedures

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is required for each sacroiliac joint injection. A completed medical review form must be submitted with documentation as outlined for prior authorization.

Prior authorization is not applicable for sacroiliac joint fusion surgery, including minimally invasive surgery for sacroiliac joint fusion.

Prior authorization is not applicable for radiofrequency ablation for sacroiliac joint pain.

Coverage

Sacroiliac joint injections are generally covered subject to the indications listed below and per your plan documents.

Sacroiliac joint fusion surgery is considered investigational/experimental and is therefore not covered.

Radiofrequency ablation for sacroiliac joint pain is considered investigational/experimental and is therefore not covered.

Indications that are covered

Sacroiliac joint injections (unilateral or bilateral) are covered to diagnose or treat sacroiliac (SI) joint pain if all of the following criteria are met:

  1. Severe pain limiting activities of daily living for at least three months despite conservative treatments (including physical therapy, activity modification, and pharmacological management), that is documented in the clinical records submitted for prior authorization.

Conservative therapy must include physical therapy (PT) and may include activity modification, weight loss, and drug therapy. Documentation must correspond to the current episode of pain (within six months).
Formal physical therapy
, at least four visits over a six week course, including active muscle conditioning is required, or there must be an explicit statement in the clinical documents that explains why such physical therapy is contraindicated. The requirement for physical therapy will not be met if there is a failure to complete prescribed physical therapy for non-clinical reasons. Documentation of formal physical therapy would be the therapist’s notes. If a patient is unable to complete physical therapy (PT) due to progressively, worsening pain and disability, the case will be reviewed on an individual basis by an internal physician reviewer. Documentation in the physical therapist’s notes demonstrating this must be submitted; and

  1. Pain is below the L5 level – low back and buttock pain with or without groin pain.
  2. Repeat injections are covered if the patient has achieved significant benefit after the first injection and symptoms have reoccurred.
  3. A maximum of three injections per 12 month period will be authorized if coverage criteria are met.

Indications that are not covered

  1. Sacroiliac joint injections are not covered when performed without guidance by real-time fluoroscopic imaging.
  2. Sacroiliac joint fusion surgery including minimally invasive surgery for sacroiliac joint fusion, including but not limited to use of iFuse implant system, is considered experimental and investigational and not covered because there is not published peer reviewed scientific evidence to prove effectiveness.
  3. Sacroiliac joint radiofrequency ablation (RFA), conventional cooled, laser or other variations, is considered experimental and investigational and not covered because there is not published peer reviewed scientific evidence to prove effectiveness.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

Codes that may be covered after prior authorization

Sacroiliac Joint Injections

Codes

Description

27096

Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed

G0259

Injection procedure for sacroiliac joint; arthrography

G0260

Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography

Codes that are for non-covered procedures

Sacroiliac Joint Fusion

Codes

Description

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, sacroiliac joint (including obtaining graft)

Radiofrequency Ablation for sacroiliac pain

Codes

Description

64635

Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint

64636

Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure)

64999

Unlisted procedure, nervous system

CPT Copyright American Medical Association. All rights reserved.  CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. Cohen, SP, Hurley, RW, Buckenmaier, CC, III, Kurihara, C, Morlando, B, and Dragovich, A. Randomized placebo-controlled study evaluating lateral branch radiofrequency denervation for sacroiliac joint pain. Anesthesiology. 2008;109(2):279-288.
  2. ECRI Institute. (2016). iFuse Implant System (SI-Bone, Inc.) for Minimally Invasive Sacroiliac Joint Fusion. Plymouth Meeting, PA: ECRI Institute.
  3. ECRI Institute. (2017). iFuse Implant System (SI-Bone, Inc.) for Minimally Invasive Sacroiliac Joint Fusion. Plymouth Meeting, PA: ECRI Institute.
  4. Hayes Inc. Hayes Medical Technology Directory Report. Radiofrequency Ablation for Sacroiliac Joint Denervation for Chronic Low Back Pain. Lansdale, PA: Hayes, Inc. February 2017.
  5. Hayes Inc. Hayes Medical Technology Directory Report. Radiofrequency Ablation for Sacroiliac Joint Pain. Lansdale, PA: Hayes, Inc. August, 2012. Reviewed May, 2016.
  6. Hayes Inc. Hayes Health Technology Brief. Open Sacroiliac Joint Fusion for Unspecified Sacroiliac Joint Dysfunction. Lansdale, PA: Hayes, Inc. June, 2017.
  7. Hayes Inc. Hayes Health Technology Brief. Open Surgery for Sacroiliac Joint Fusion for the Treatment of Low Back Pain. Lansdale, PA: Hayes, Inc. March 2014. Reviewed January 2016.
  8. Hayes Inc. Hayes Health Technology Brief. iFuse Implant System (SI-BONE Inc.) for Sacroiliac Joint Fusion for Treatment of Low Back Pain. Lansdale, PA: Hayes, Inc.September 2015. Reviewed September, 2016 (a).
  9. Hayes, Inc. Hayes Health Technology Brief. iFuse Implant System (SI-Bone Inc.) for Sacroiliac Joint Fusion for Treatment of Low Back Pain. Lansdale, PA: Hayes, Inc.; December 2016 (b).
  10. Hayes, Inc. Hayes Health Technology Brief. iFuse Implant System (SI-Bone Inc.) for Sacroiliac Joint Fusion for Treatment of Sacroiliac Joint Dysfunction. Lansdale, PA: Hayes, Inc.; November, 2017.
  11. Hayes, Inc. Hayes Health Technology Brief. Sacroiliac Joint Injections with Corticosteroids for Treatment of Chronic Low Back Pain. Lansdale, PA: Hayes, Inc.; December, 2016.
  12. Kibsgård TJ, Røise O, Sudmann E, Stuge B. “Pelvic joint fusions in patients with chronic pelvic girdle pain: a 23-year follow-up.” Eur Spine J. 2013;22(4):871-877.
  13. Ledonio CG, Polly DW Jr, Swiontkowski MF. Minimally invasive versus open sacroiliac joint fusion: are they similarly safe and effective? Clin Orthop Relat Res. 2014;472(6):1831-1838.
  14. Polly DW, Cher DJ, Wine KD, et al. Randomized controlled trial of minimally invasive sacroiliac joint fusion using triangular titanium implants vs nonsurgical management for sacroiliac joint dysfunction: 12-month outcomes. Neurosurgery. 2015.
  15. Rupert, et al. “Evaluation of SI Joint Interventions: A Systematic Appraisal of the Literature.” Pain Physician 2009; 12:399-418.
  16. Smith AG, Capobianco R, Cher D, et al. Open versus minimally invasive sacroiliac joint fusion: a multi-center comparison of perioperative measures and clinical outcomes. Ann Surg Innov Res. 2013;7(1):14.
  17. Whang P, Cher D, Polly D, et al. Sacroiliac joint fusion using triangular titanium implants vs. nonsurgical management: six-month outcomes from a prospective randomized controlled trial. Int J Spine Surg. 2015;9:6.
  18. Wise CL, Dall BE. “Minimally invasive sacroiliac arthrodesis: outcomes of a new technique.” J Spinal Disord Tech. 2008 Dec;21(8):579-84.

Go to

Policy activity

  • 02/25/2009 - Date of origin
  • 02/09/2018 - Effective date
Review date
  • 02/2018
Revision date
  • 06/21/2016

Related content