Many health insurance plans have established patient selection guidelines for minimally invasive SI joint fusion. Like all procedures, your medical records must justify why a minimally invasive SI joint fusion procedure is the right procedure for you.
Some health plans have their own internal patient selection guidelines. Other plans follow guidelines published by professional medical societies and other technology assessment organizations, including guidelines by North American Spine Society (NASS), International Society of Advancement of Spine Surgery (ISASS), and AIM Specialty Health (AIM).
Below are commonly referenced patient criteria for minimally invasive SI joint fusion (check with your plan for specific procedure guidelines):
- Have undergone and failed a minimum six months of conservative care, including medications, activity modification, bracing, and physical therapy targeted at your lumbar spine, pelvis, SI joint and hip, including a home exercise program.
- Typically, unilateral pain that is below your lumbar spine (L5 vertebrae), localized over your posterior SI joint, and consistent with your SI joint pain.
- A thorough physical exam demonstrating: localized tenderness with palpation over your sacral sulcus (Fortin Finger, see image) in the absence of tenderness of similar severity elsewhere and other obvious sources for pain do not exist.
- Absence of generalized pain behavior (e.g., somatoform disorder) or generalized pain disorders (e.g., fibromyalgia).
- Positive response to a cluster of 3 provocative tests (Distraction, Thigh Thrust, FABER Compression test, Gaenslen’s test).
- Imaging to rule out other conditions, such as x-rays, CT scan, or MRI of your lumbar spine, hip and pelvis.
- Short-term pain relief during the anesthetic phase of your intra-articular diagnostic SI joint injection.
- At least one therapeutic SI joint injection(corticosteroid injection).
Below is a list of health plans that cover minimally invasive SI joint fusion (through April 2018)
National Government Policies:
- Medicaid – 44 state programs and Washington DC
- Medicare – all Medicare Administrative Contractors (MACs)
- Tricare – coverage for U.S. uniformed service members and their families around the world
Coverage Policies Exclusively with the iFuse Implant System® (triangular titanium implants):
- Florida Blue
- Idaho, Blue Cross
- Illinois, Blue Cross Blue Shield (HCSC)
- Kansas, Blue Cross Blue Shield (effective May 1, 2018)
- Kansas City, Blue Cross Blue Shield
- Louisiana, Blue Cross Blue Shield
- Minnesota, Blue Cross Blue Shield
- Mississippi, Blue Cross Blue Shield
- Montana, Blue Cross Blue Shield (HCSC)
- New Jersey (Horizon Blue Cross Blue Shield)
- New Mexico, Blue Cross Blue Shield (HCSC)
- North Dakota, Blue Cross Blue Shield
- Oklahoma, Blue Cross Blue Shield (HCSC)
- South Carolina, Blue Cross Blue Shield
- Tennessee, Blue Cross Blue Shield (effective May 1, 2018)
- Texas, Blue Cross Blue Shield (HCSC)
- Wyoming, Blue Cross Blue Shield
- Molina Healthcare (Northwest)
Covers MIS SI Joint Fusion
- Delaware (Highmark Blue Cross Blue Shield)
- Michigan, Blue Cross Blue Shield Blue Care Network
- Nebraska, Blue Cross Blue Shield
- Pennsylvania (Highmark Blue Cross Blue Shield)
- Vermont, Blue Cross Blue Shield
- West Virginia (Highmark Blue Cross Blue Shield)
- Emblem Health of NY
- Geisinger Health Plan
- Harvard Pilgrim
- Health New England
- Inland Empire Health Plan (IEHP)
- Kaiser Permanente (California & Northwest)
- Kern Health Systems
- Minuteman Health
- Network Health
- PEHP Health & Benefits (Nonprofit trust providing benefits to Utah’s public employees)
- Priority Health
- UnitedHealthcare (case-by-case basis, covers every case with documentation)
Please contact our Patient Insurance Coverage Support (PICS) team with any questions about your insurance plan’s coverage policy for this procedure (PICs@si-bone.com)