Checklist of Information to Gather for a Prior Authorization

Patient Education

Below is a checklist of items to include in a request for prior authorization.  Ensure that your surgeon has copies of these documents to initiate the request: 

  • Your surgeon will complete a letter of medical necessity including your diagnoses, your proposed surgery date, and why the procedure is appropriate to treat your condition.
  • Prior Authorization Form, available from your plan (if applicable).
  • Chart notes related to your SI joint condition and your surgeon’s recommendation for surgery.1
  • Imaging studies (i.e., pelvis, hip, and/or lumbar spine). These may include x-rays, CT scans or MRI.
  • Physician clinic notes from other providers treating you for the condition.  This may include your PCP, physical therapist, and pain management physician.
  • Peer reviewed clinical studies to support the safety and efficacy of minimally invasive SI joint fusion procedures.
  • Professional medical society statements on patient selection of SI joint fusion (NASS and ISASS).

Contact SI-BONE’s Reimbursement Support Team for insurance coverage information: by phone (800-710-8511) or email (PICS@si-bone.com).

1. The notes should include documentation of tried and failed treatments to resolve your SI joint condition (i.e., physical therapy, current medications related to the condition, pain relief from therapeutic SI joint injection(s)).

 

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