Local Coverage Determination (LCD)

Percutaneous minimally invasive fusion/stabilization of the sacroiliac joint for the treatment of back pain

L36000

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Proposed LCD
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Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L36000
Original ICD-9 LCD ID
Not Applicable
LCD Title
Percutaneous minimally invasive fusion/stabilization of the sacroiliac joint for the treatment of back pain
Proposed LCD in Comment Period
N/A
Source Proposed LCD
DL36000
Original Effective Date
For services performed on or after 12/17/2015
Revision Effective Date
For services performed on or after 06/27/2024
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
11/01/2015
Notice Period End Date
12/16/2015

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Issue

Issue Description

Review completed with no change in coverage

Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Title XVIII of the Social Security Act, Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) allows coverage and payment for services considered medically reasonable and necessary.

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

The sacroiliac (SI) joints are formed by the connection of the sacrum and the right and left iliac bones. The sacrum is the triangular-shaped bone in the lower portion of the spine, below the lumbar spine. While most of the bones (vertebrae) of the spine are mobile, the sacrum is made up of 5 vertebrae that are fused together and do not move. The iliac bones are the 2 large bones that make up the pelvis. As a result, the SI joints connect the spine to the pelvis. The sacrum and the iliac bones (ileum) are held together by a collection of strong ligaments. There is relatively little motion at the SI joints. There are normally less than 4 degrees of rotation and 2 mm of translation at these joints.

Indications
Percutaneous minimally invasive fusion/stabilization of the sacroiliac joint (SIJ) for the treatment of back pain is indicated for the treatment of SIJ pain for patients with low back/buttock pain who meet all of the following criteria:

a) Have undergone and failed a minimum 6 months of intensive non-operative treatment that must include medication optimization, activity modification, and active physical therapy;

b) Patient’s report of non-radiating, unilateral pain that is caudal to the lumbar spine (L5 vertebrae), localized over the posterior SIJ, and consistent with SIJ pain;

c) Localized tenderness with palpation of the posterior SIJ in the absence of tenderness of similar severity elsewhere (e.g. greater trochanter, lumbar spine, coccyx) and other obvious sources for their pain do not exist;

d) Positive response to the thigh thrust test OR compression test AND 2 of the following additional provocative tests: Gaenslen’s test, Distraction test, Patrick’s sign;

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

f) Diagnostic imaging studies that include ALL of the following:

1. Imaging (plain radiographs and a CT or MRI) of the SI joint that excludes the presence of destructive lesions (e.g. tumor, infection) or inflammatory arthropathy that would not be properly addressed by percutaneous SIJ fusion;

2. Imaging of the ipsilateral hip (plain radiographs) to rule out osteoarthritis;

3. 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;

g) At least 75 percent reduction of pain for the expected duration of the anesthetic used following an image-guided, contrast-enhanced SIJ injection on two separate occasions.

Limitations
Percutaneous SIJ fusion for SIJ pain is not indicated in the presence of:

Systemic arthropathy such as ankylosing spondylitis or rheumatoid arthritis;

Generalized pain behavior (e.g. somatoform disorder) or generalized pain disorder (e.g. fibromyalgia);

Infection, tumor, or fracture;

Acute, traumatic instability of the SIJ;

Neural compression as seen on an MRI or CT that correlates with the patient’s symptoms or other more likely source for their pain.

Summary of Evidence

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Analysis of Evidence (Rationale for Determination)

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Proposed Process Information

Synopsis of Changes
Changes Fields Changed
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Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
View Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description

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Revenue Codes

Code Description

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CPT/HCPCS Codes

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ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph:

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Group 1 Codes:

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ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph:

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Group 1 Codes:

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Additional ICD-10 Information

General Information

Associated Information
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Sources of Information
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Bibliography

Heini PF, Klinik S. Reviewer's comment concerning "The percutaneous stabilization of the sacroiliac joint with hollow modular anchorage screws: a prospective outcome study" by Lyndon W. Mason, Iqroop Chopra and Khitish Mohanty. European Spine Journal. 2013;22(10): 2332.

Mason LW, Chopra I, Mohanty K. The percutaneous stabilization of the sacroiliac joint with hollow modular anchorage screws: a prospective outcome study. European Spine Journal. 2013;22(10):2335-2331.

Miller LE, Block JE. Minimally invasive arthrodesis for chronic sacroiliac joint dysfunction using the SImmetry SI Joint Fusion system. Medical Devices. 2014;7:125-130.

NASS Coverage Committee. Sacroiliac Joint Fusion, defining appropriate coverage positions. North American Spine Society. 2015.

Sachs D, Capobianco R. One year successful outcomes for novel sacroiliac joint arthrodesis system. Annals of Surgical Innovation and Research. 2012;6(13):1-4.

Shaffrey CI, Smith JS. Stabilization of the sacroiliac joint. Neurosurgical Focus. 2013;35(2 Suppl):Editorial. doi: 10.3171/2013.V2.FOCUS13273

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
06/27/2024 R8

Posted 6/27/2024: Review completed 5/16/2024. No changes to coverage. Updates made throughout to AMA formatting.

  • Other ((Review) )
06/30/2022 R7

Posted 06/30/2022: Review completed 06/06/2022. Moved references listed under Sources of Information to Bibliography, and corrected formatting to reflect AMA guidelines.

  • Other ((Review))
06/25/2020 R6

06/25/2020 Documentation Requirements Section removed due to redundancy since already located in A57596 Billing and Coding: Percutaneous minimally invasive fusion/stabilization of the sacroiliac joint for the treatment of back pain. Review completed 06/04/2020 with no change in coverage.

  • Other (Review)
11/01/2019 R5

Change Request 10901 Local Coverage Determinations (LCDs): it will no longer be appropriate to
include Current Procedure Terminology (CPT)/Health Care Procedure Coding System (HCPCS) codes or
International Classification of Diseases Tenth Revision-Clinical Modification (ICD-10-CM) codes in
the LCDs. All CPT/HCPCS, ICD-10 codes, and Billing and Coding Guidelines have been removed from
this LCD and placed in the Billing and Coding Article related to this LCD. Consistent with Change
Request 10901, if any language from IOMs and/or regulations was present in the LCD, it has been
removed and the applicable manual/regulation has been referenced.

  • Revisions Due To Code Removal
09/01/2018 R4

09/01/2018 Annual review completed 08/07/2018 with no changes in coverage. Acronym SIJ added to Indications for sacroiliac joint. Typographical error corrected.

  • Other (Annual review)
09/01/2017 R3

09/01/2017 Annual review completed 08/09/2017 with no changes in coverage. Typographical error corrected.  At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 

  • Other (Annual Review )
02/01/2016 R2 10/01/2016 Annual review, no changes in coverage.
  • Other (Annual review)
02/01/2016 R1 02/01/2016 Removed CAC information no change in coverage.
  • Other
N/A

Associated Documents

Attachments
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Related National Coverage Documents
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Public Versions
Updated On Effective Dates Status
06/18/2024 06/27/2024 - N/A Currently in Effect You are here
06/23/2022 06/30/2022 - 06/26/2024 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

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