I. Disclaimer

This document is intended to be used as a reference for non-VA providers and not intended to replace clinical judgment when determining care pathways. These guidelines do not guarantee benefits or constitute medical advice.

II. Clinical Determinations and Indication

1. Indications
   1. Indications for Minimally Invasive Sacroiliac (SI) Joint Fusion with Placement of a Transfixation Device 
      Minimally invasive SI joint fusion is indicated for the treatment of SI joint pain and will be considered medically necessary when ALL the following criteria are met: 
      • Moderate to severe low back pain primarily experienced over the anatomical location of the SI joints 
      • SI joint pain, measured on a pain scale, causing functional impairment 
      • Pain confirmed to originate from the SI joint 
        • Localized tenderness over the sacral sulcus with absence of tenderness of similar severity elsewhere (e.g., greater trochanter, lumbar spine, coccyx) 
        • SI joint pain does not originate from generalized pain behavior (e.g., somatoform disorder) or generalized pain disorders (e.g., fibromyalgia) 
        • At least three positive findings with provocative maneuvers: 
          • Flexion abduction external rotation (FABER) or Patrick’s test, thigh thrust test or posterior shear, SI joint compression, Gaenslen’s test, SI joint distraction, and Yeoman test 
      • Persistent pain despite a minimum of six months of intensive non-operative treatment that includes: 
        • Medication optimization 
        • Activity modification 
        • Active therapeutic exercise targeted at the lumbar spine, pelvis, SI joint, and hip, including a home exercise program 
        • Consideration of bracing 
      • Veteran must receive ALL the following diagnostic imaging studies: 
        • Imaging of the SI joint (plain radiographs and a computed tomography (CT) or magnetic resonance imaging (MRI)) to rule out the presence of destructive lesions (e.g., tumor, infection), fracture, traumatic SI joint instability, or inflammatory arthropathy that would not be properly addressed by minimally invasive SI joint fusion 
        • Imaging of the pelvis to determine SI joint pain is not due to concomitant hip pathology (e.g., x-rays) 
        • Imaging of the lumbar spine (CT or MRI) to determine SI joint pain is not due to neural compression or other degenerative conditions that can cause low back or buttock pain 
      • Veteran completed a trial of image-guided, contrast-enhanced intra-articular SI joint injection to confirm the diagnosis and has experienced at least 75% reduction of pain for the expected duration of two anesthetics (on separate visits each with a different duration of action), as measured by an approved pain scale 
      • Veteran completed at least one trial of a therapeutic intra-articular injection (e.g., corticosteroid injection), unless contraindicated 
      • Considered radiofrequency ablation as an alternative treatment option for SI joint pain prior to offering minimally invasive surgical fusion 
        
   2. Indications for Open Sacroiliac Joint Fusion 
      Open SI joint fusion is considered medically necessary for treating ANY of the following indications: 
      1. Stabilization of the SI joint post-traumatic injury (e.g., following pelvic ring fracture and/or other radiographically-documented ligamentous disruption) 
      2. As an adjunct to sacrectomy or partial sacrectomy in the management of a sacral tumor 
      3. As an adjunctive medical treatment of SI joint infection (e.g., osteomyelitis, pyogenic sacroiliitis) or sepsis 
      4. When performed as part of multi-segmental spinal fusion for the correction of spinal deformity (e.g., scoliosis) 

Note: Appropriate imaging studies must demonstrate localized SI joint pathology 

2. Limitations/Exclusions
3. Conditions/indications for which minimally invasive SI joint fusion is not medically necessary include, but are not limited to, the following: 
   1. Systemic arthropathy such as ankylosing spondylitis or rheumatoid arthritis 
   2. SI joint pain that cannot be differentiated from generalized pain behavior (e.g., somatoform disorder) or generalized pain disorder (e.g., fibromyalgia) 
   3. Infection, tumor, or fracture 
   4. Acute, instability of the SI joint due to trauma 
   5. Presence of neural compression as seen on an MRI or CT that correlates with the Veteran’s symptoms or other more likely source for their pain (e.g., radicular pain) 
   6. Minimally invasive fusion of the SI joint WITHOUT placement of a transfixation device 
4. 
   For any conditions/indications not listed in section II.a. of this document, minimally invasive or open SI joint fusion/stabilization is considered not medically necessary due to insufficient evidence of efficacy and safety. 
   
5. Description of Treatment 
6. Minimally Invasive Sacroiliac Joint Fusion / Stabilization 
7. Minimally invasive surgical fusion of the SI joint is achieved with the Veteran in a level position, under general or spinal anesthesia. There are multiple techniques for this procedure and the lateral approach is most common. Under fluoroscopic guidance, the SI joint is accessed laterally through a small incision made in the buttock to reach the ilium. A pin is passed through the ilium across the SI joint into the center of the sacrum, avoiding the neural foramen. A drill is used to create a pathway through the ilium to the sacrum. An implant (with the lateral portion of the implant sitting in the ilium and the medial end in the sacrum) is inserted, spanning the SI joint. Typically, three implants are used, which can be placed during the same procedures or in staged procedures. Veterans are advised to gradually return to full weight bearing over several weeks, using a walker for assistance, followed by physiotherapy. 

Open Sacroiliac Joint Fusion 
Open SI joint fusion is achieved with the Veteran laying prone (face down) under general anesthesia. A surgical incision is made to separate the muscles and tissue, allowing access to the joint. Cartilage is then removed between the sacrum and ilium, and a bone graft is taken from the pelvis to connect and stabilize the joint. Screws are inserted to keep the graft in place during healing. The sacrum and iliac bones are held together with the bone grafts and screws until they fuse, stopping the movement between the bones to alleviate joint pain or preventing further injury. For some fractures and/or radiographically-documented ligamentous injuries to the SI joint, it may be possible to reduce the fracture or radiographically-documented ligamentous disruption through closed reduction followed by percutaneous fixation.  While this is a minimally invasive procedure, the indications and requirements described in II.a only apply to the scenario of SI joint pain in the absence of fracture or radiographically-documented ligamentous injury. 

III. Background and Supporting Information

The following information is for reference purposes only in accordance with the medical benefits package outlined in 38 C.F.R. § 17.38 (b). Each subsection supports VA’s determinations for medical necessity and alignment with generally accepted standards of medical practice. 

1. Background Information
   Chronic lower back pain triggered from the sacroiliac (SI) joint occurs in 15-30% of patients. The convergence of sensory pathways from the hip, SI joint, and lumbar spine may result in overlapping pain patterns due to dysfunction of these structures. Proper SI joint pain diagnosis is key to providing appropriate patient care. Patients with SI joint pain typically report pain in the buttock(s), with possible radiation into the groin or upper legs. Potential causes of SI joint pain can be traumatic or atraumatic. Traumatic causes may result from pelvic ring fractures, soft tissue injury from a fall onto the buttock, indirect injury from a motor vehicle collision, or sudden/repeated heavy lifting/strain or torsion. Atraumatic causes can include spondyloarthropathy, enthesopathy, osteoarthritis, infection, previous lumbar fusion, pregnancy, leg length discrepancy, and scoliosis. The spectrum of pain and disability from SI joint dysfunction is wide-ranging. 

Non-operative treatments for SI joint pain include analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), physiotherapy, manipulative therapy, intra-articular SI joint corticosteroid injections, periarticular injections, botulinum toxin injections, and radiofrequency denervation. Surgical treatment is considered for persistent chronic symptoms that are unresponsive to conservative treatment. Surgical techniques include minimally invasive SI joint fusion with placement of a transfixation device to stabilize and treat joint pain. 

2. Research, Clinical Trials, and Evidence Summaries
   Minimally invasive SI joint fusions have proven to be an efficient method of treatment to provide relief for patients with SI joint pain. Open SI joint fusions have proven to be appropriate and effective for relieving SI joint pain for specific clinical conditions such as instability of the SI joint post-traumatic injury, sacral tumors, SI joint infection or sepsis, or spinal deformity. Studies demonstrate patient reported improvements in health-related quality of life (HRQoL), pain, and clinical improvements both physically and mentally after minimally invasive SI joint fusion. Both procedures have been deemed safe with minimal adverse events. Evidence for the safety and efficacy of minimally invasive SI joint fusion has grown substantially over the past decade. 

1. Smith et al. (2014) conducted a multi-center, retrospective comparative cohort study of patients who underwent SI joint fusion using either an open surgical technique or a minimally invasive surgical technique. Operative measures including surgical operating time, length of hospitalization, and estimated blood loss (EBL) were collected along with demographics, medical history, surgical complications, and 12 and 24-month pain scores. Data included 263 patients treated by seven surgeons; 149 patients treated with open surgical technique and 114 treated with minimally invasive SI joint fusion. Measures of EBL, operating time, and length of hospitalization were significantly lower for minimally invasive surgical technique than open surgical technique. Pain relief, measured as change from baseline to 12 months in visual analog scale (VAS) pain rating, was 3.5 points lower in the minimally invasive surgery group than the open surgical technique group. When matched for age, gender, and a history of prior lumbar spinal fusion, postoperative pain scores were on average three points lower for minimally invasive surgery versus open surgical technique. Results of the multi-center comparative study demonstrated patients who underwent either open or minimally invasive SI joint fusion showed postoperative improvements in pain scores. Compared to open surgical technique patients, patients who underwent minimally invasive SI joint fusion had significantly greater pain relief and more favorable perioperative surgical measures. 
2. 
   Ghaddaf et al. (2024) performed a systematic review and meta-analysis to compare minimally invasive SI joint fusion with triangular titanium implants (TTI) to nonoperative management of SI joint dysfunction. The analysis included eight articles representing three trials with a total of 423 participants. Results were reported by two separate methods. The first method included 261 participants of which 54 underwent minimally invasive SI joint fusion and were compared to 97 who received nonoperative management. The second method included 172 participants who all underwent minimally invasive SI joint fusion, and their outcomes were compared to their own baseline nonoperative management. For both groups the Oswestry Disability Index (ODI) score, Short Form Health Survey (SF-36) physical component scores (PCS), mental component summary (MCS) scores, patient satisfaction, and adverse events were substantially improved for participants who received minimally invasive SI joint fusion. Significant and clinically important improvements in pain, disability, HRQoL, and patient satisfaction were reported with minimally invasive SI joint fusion with TTI compared with nonoperative management for SI joint dysfunction. Similarly, significantly fewer patients who had minimally invasive SI joint fusion than those who received nonoperative management were using opioids. No substantial difference in the rate of adverse events between minimally invasive SI joint fusion and nonoperative management were noted. 
3. 
   Schmidt et al. (2021) conducted a single center retrospective cohort study including patients who underwent minimally invasive SI joint fusion. Patient selection criteria for surgical candidates were based on short‐term resolution of symptoms (80% or greater relief) with an image‐guided intra‐articular injection of local anesthetic of the SI joint. Patients completed preoperative and postoperative VAS and SF‐36 questionnaires to assess outcomes. Based on response to local anesthesia, patients were diagnosed with sacroiliitis or SI dysfunction. Nineteen patients comprising of 24 SI fusions, with a mean follow-up of 58 months were included. All patients showed improvement in their SF‐36 physical function scores and 18 of 19 showed improvement in the VAS score. In appropriately selected patients, minimally invasive SI joint fusion results in decreased pain and improved physical functioning of patients, which is sustained for more than four years post‐procedure. 
4. 
   A systematic review and meta-analysis of safety and efficacy of patients undergoing SI joint fusion was performed by Whang et al. (2024). Patient-reported outcomes (PROs) and safety measures were stratified by surgical technique: including lateral transiliac (LTI), posterolateral transiliac (PLTI), and posterior interpositional (PI) procedures. Efficacy results were reported in 57 cohorts (2851 patients) for pain scores and 37 cohorts (1978 patients) for ODI scores. Safety outcomes were reported on 63 cohorts (3162 patients). All studies with PROs showed improvement from baseline after surgery. Meta-analytic improvements in pain scores were highest for LTI, slightly lower for PLTI, and lowest for PI procedures. Improvements in ODI scores were highest for LTI, lowest for PLTI procedures, and intermediate for PI. Results indicate that minimally invasive SI joint fusion provides high levels of pain relief and disability improvement with a reasonable safety profile. 
5. 
   Hsu et al. (2010) conducted a retrospective review of radiographic and clinical results for patients treated with open reduction for displaced sacral fractures. Twenty patients were included in the review with complete clinical follow-up available on 19 patients. The average duration of follow-up was 3.7 years. Follow up results showed that additional surgery was not required, and no infections, additional neurologic deficits, or vascular injuries were reported. There was one asymptomatic hardware failure two years postoperatively with no further displacement. Average preoperative displacement on the anteroposterior (AP) radiograph was 14.72 mm with a long-term follow-up displacement of 3.25 mm. Iowa Pelvic Score questionnaires demonstrated an average score of 92.2. Eighty-nine percent of patients returned to full time work or their previous activity level. Open reduction and fixation of displaced sacral fractures described in the review was found to be safe and effective with a low complication rate and clinical results. 

3. U.S. Food & Drug Administration (FDA) Information 
4. VA generally only approves use of medical devices that have received at least FDA clearance for 510(k) Premarket Notification. The FDA has determined these Class II devices are substantially equivalent (SE) to legally marketed predicate devices and may be marketed in the U.S.

To search for devices that have received FDA 510(k) clearance or Premarket Approval (PMA), please visit the FDA Devices database. 

4. Medicare Coverage Determinations 
5. Available Medicare national and local coverage determinations are listed below as a resource. VA and Medicare are governed by separate laws and regulations; thus, VA coverage determinations may be different. 

   NCD Number	Name	Effective Date
   None	N/A	N/A

   LCD Number	Contractor	Original/Revision Effective Date
   L36406	Wellpoint Federal	04/01/2026
   L36000	Wisconsin Physicians Service Insurance Corporation	06/27/2024

   • NCD: National Coverage Determination
   • LCD: Local Coverage Determination
     

5. TRICARE Policy Manual 
   Available TRICARE coverage determinations are listed below as a resource. VA and TRICARE are governed by separate laws and regulations; thus, VA coverage determinations may be different. 
   
6. TRICARE Policy Manual 6010.63-M, Chapter 04, Section 4.11 
   

6. Health Care Procedural Coding Information 
7. The following CPT^®/HCPCS codes listed in this section are provided for informational purposes only. Inclusion or exclusion of a code does not constitute or imply VA coverage or provider reimbursement. The list of codes may not be all-inclusive since the American Medical Association (AMA) and Centers for Medicare & Medicaid Services (CMS) code updates may occur more frequently than CDI updates. Please refer to section II.a. in this document to review indications and clinical criteria for medical necessity. 
8. 
   The following CPT/HCPCS codes are considered medically necessary/covered if the indications and clinical criteria outlined in section II.a. are met. Additional codes may also apply. 

CPT/HCPCS Code	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, open, includes obtaining bone graft, including instrumentation, when performed

CPT copyright ^© 2026 American Medical Association. All rights reserved.

IV. Definitions

Term	Definition
Bracing	Use of orthopedic appliance or apparatus to restrict movement and relieve pressure
Caudal	Used in describing anatomic location and direction, toward the tail
Enthesopathy	A disorder of the entheses connective tissues between bones and tendons or ligaments; occurs when these tissues have been damaged due to overuse, injury, or infection
Fibromyalgia	A disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory, and mood issues
Ilium	The broad, upper, and largest of the three bones composing either side of the pelvis
Neural foramen	Critical structures in the spine that contain exiting nerve roots
Osteoarthritis	A degenerative joint disease that worsens over time related to bone structures, often resulting in chronic pain
Posterior interpositional approach	Placing implants (either structural bone allografts or metallic devices) directly into the sacroiliac joint from a posterior approach without joint transfixation
Sacral sulcus	An anatomic location pertaining to the lateral aspect of the sacrum at the level of S1 and S2, and medial to the posterior superior iliac spine
Sacrum	A bone structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis
Somatoform disorder	A group of disorders characterized by physical symptoms, not explained by organic factors
Spondyloarthropathy	Inflammatory arthritis affecting the spine
Transiliac	Extending from one ilium or iliac crest or spine to the other

V. References

Defense Health Agency (2021, April 6). Musculoskeletal System. TRICARE Policy Manual 6010.63-M. Chapter 04, Section 6.1. Retrieved March 20, 2024.

Ghaddaf, A. A., Alsharef, J. F., Alsharef, N. K., Alsaegh, M. H., Alshaban, R. M., Almutairi, A. O., Abualola, A. H., & Alshehri, M. S. (2024). Minimally invasive sacroiliac joint fusion using triangular titanium implants versus nonsurgical management for sacroiliac joint dysfunction: a systematic review and meta-analysis. Canadian journal of surgery. Journal canadien de chirurgie, 67(1), E16–E26. 

Hsu, J. R., Bear, R. R., & Dickson, K. F. (2010). Open reduction internal fixation of displaced sacral fractures: technique and results. Orthopedics, 33(10), 730. 

International Society for the Advancement of spine Surgery. (2016, July 7). ISASS Policy Statement – Minimally Invasive Sacroiliac Joint Fusion. Retrieved March 19, 2024.

MCG Health. (2024, March 14). Musculoskeletal Surgery or Procedure GRG. Ambulatory Care. 27th Edition. 

Medicare Coverage Database (n.d.). Retrieved March 21, 2024.

National Institute for Health and Care excellence. (2017, April 5). Minimally invasive sacroiliac joint fusion surgery for chronic sacroiliac pain: Guidance. Retrieved March 19, 2024.

Raj, M. A. (2023, August 14). Sacroiliac Joint pain. StatPearls [Internet]. 

Schmidt, G., Bologna, M., & Schorr, R. (2021). Patient Reported Clinical Outcomes of Minimally Invasive Sacroiliac Joint Arthrodesis. Orthopaedic surgery, 13(1), 71–76. 

Smith, A. G., Capobianco, R., Cher, D., Rudolf, L., Sachs, D., Gundanna, M., Kleiner, J., Mody, M. G., & Shamie, A. N. (2013). Open versus minimally invasive sacroiliac joint fusion: a multi-center comparison of perioperative measures and clinical outcomes. Annals of surgical innovation and research, 7(1), 14. 

U.S. Food & Drug Administration Medical Devices Database. (n.d.). Retrieved March 12, 2024.

Whang, P. G., Patel, V., Duhon, B., Sturesson, B., Cher, D., Carlton Reckling, W., Capobianco, R., & Polly, D. (2023). Minimally Invasive SI Joint Fusion Procedures for Chronic SI Joint Pain: Systematic Review and Meta-Analysis of Safety and Efficacy. International journal of spine surgery, 17(6), 794–808. 

VI. CDI History/Revision Information

Date	Summary of Updates
06/01/2025	New CDI created describing medically necessary and not medically necessary indications

---