Axial Lumbosacral Interbody Fusion

Axial lumbosacral interbody fusion (Axial LIF, also called pre-sacral, trans-sacral, or paracoccygeal interbody fusion) is a minimally invasive technique that is performed under fluoroscopic guidance. This procedure is designed to provide anterior access to the L5-S1 disc spaces for interbody fusion.

Sacroiliac Joint Fusion

Sacroiliac joint (SIJ) fusion is a treatment for sacroiliac joint conditions such as joint damage resulting from trauma, infection, cancer, and joint instability (e.g. pelvic fracture). SIJ fusion may be performed as a minimally invasive procedure or as an open surgical procedure. Percutaneous sacroiliac joint fusion is a minimally invasive approach in which instrumentation involving cages or screws, with or without bone graft, are placed percutaneously in order to achieve a fusion. 

Sacroiliac Joint Fusion - Open

SIJ fusion may be considered medically necessary when ALL of the following criteria are met:

• Appropriate imaging studies demonstrate localized sacroiliac joint pathology; and
• The individual is a nonsmoker, or in the absence of progressive neurological compromise will refrain from use of tobacco products for at least six (6) weeks prior to the planned surgery; and 
• ANY of the following:
  • Post-traumatic injury of the SIJ (e.g., following pelvic ring fracture); or
  • As an adjunctive treatment for SIJ infection or sepsis; or
  • Management of sacral tumor (e.g., partial sacrectomy); or
  • When performed as part of multisegmental long fusions for the correction of spinal deformity (e.g., idiopathic scoliosis, neuromuscular scoliosis).

SIJ fusion is considered experimental/investigational and therefore non-covered for ALL of the following conditions because the safety and/or effectiveness of this procedure cannot be established by the available published peer-reviewed literature:

• Mechanical low back pain; and
• SIJ syndrome; and
• Degenerative sacroiliac joint; and
• Radicular pain syndromes.

SIJ fusion performed for any other indication not listed above will be considered not medically necessary.

Sacroiliac Joint Fusion – Percutaneous or Minimally Invasive

Percutaneous or minimally invasive SIJ fusion using a FDA-approved implant may be considered medically necessary when ALL of the following criteria are met:

·         Failure to respond (i.e., continued pain that interferes with activities of daily living and/or results in functional disability) to a minimum of six (6) months of intensive nonoperative treatment that must include medication optimization, activity modification, bracing and active therapeutic exercise targeted at the lumbar spine, pelvis, SIJ and hip including a home exercise program; and

·         Reported pain is typically unilateral pain that is caudal to the lumbar spine (L5 vertebra), localized over the posterior SIJ, and consistent with SIJ pain; and

·         Thorough physical examination demonstrates localized tenderness with palpation over the sacral sulcus (Fortin’s point, ie, at the insertion of the long dorsal ligament inferior to the posterior superior iliac spine or PSIS) in the absence of tenderness of similar severity elsewhere (e.g., greater trochanter, lumbar spine, coccyx) and that other obvious sources for their pain do not exist; and

·         Positive response to a cluster of three (3) provocative tests (e.g., thigh thrust test, compression test, Gaenslen’s test, distraction test, Patrick’s sign, posterior provocation test);

o    Note: thrust test is not recommended in pregnant patients or those with connective tissue disorders; and

·         Absence of generalized pain behavior (e.g., somatoform disorder) or generalized pain disorders (e.g., fibromyalgia); and

·         Diagnostic imaging studies that include ALL of the following:

o    Imaging (plain radiographs and a CT [computed tomography] or MRI [magnetic resonance imaging]) of the SIJ that excludes the presence of destructive lesions (e.g., tumor, infection) or inflammatory arthropathy that would not be properly addressed by percutaneous SIJ fusion; and

o    Imaging of the pelvis (AP [anteroposterior] plain radiograph) to rule out concomitant hip pathology; and

o    Imaging of the lumbar spine (CT or MRI) to rule out neural compression or other degenerative condition that can be causing low back or buttock pain; and

o    Imaging of the SIJ that indicates evidence of injury and/or degeneration; and

·         Diagnostic confirmation of the SIJ as the pain generator demonstrated by at least 75% reduction of pain for the expected duration of the anesthetic used following an image-guided, contrast-enhanced intra-articular SIJ injection on two (2) separate occasions; and

·         A trial of at least one (1) therapeutic intra-articular SIJ injection (i.e., corticosteroid injection).

Percutaneous or minimally invasive sacroiliac joint fusion for the following indications is considered experimental/investigational and therefore, non-covered because the safety and/or effectiveness of this procedure cannot be established by the available published peer-reviewed literature:

·         When ALL of the above criteria have not been met; or

·         Use of a non-FDA-approved minimally invasive or percutaneous SIJ fusion implant; or

·         Systemic arthropathy, (e.g., ankylosing spondylitis or rheumatoid arthritis); or

·         Acute, traumatic instability of the SIJ; or

·         Other pathology that would substantially prevent the patient from deriving benefit.

Axial LIF is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this procedure cannot be established by the available published peer-reviewed literature.