Description
Documentation will be reviewed to determine whether minimally invasive surgical fusion of the sacroiliac joint met Medicare coverage criteria and was reasonable and necessary.
Affected Code(s)
27279
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 CFR §405.986- Good Cause for Reopening
7. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
8. CGS Administrators, LLC, Local Coverage Determination (LCD) L36494- Minimally Invasive Surgical (MIS) Fusion of the Sacroiliac Joint (SIJ); Effective 2/01/2016; Revised 01/5/2023
9. CGS Administrators, LLC, Local Coverage Article (LCA) A56535- Billing and Coding: Minimally Invasive Surgical (MIS) Fusion of the Sacroiliac Joint (SIJ); Effective 2/01/2016; Revised 01/5/2023
10. National Government Services, Inc., LCD L36406- Minimally Invasive Surgical (MIS) Fusion of the Sacroiliac Joint (SIJ); Effective 4/01/2016; Revised 10/10/2019
11. National Government Services, Inc., LCA A57431- Billing and Coding: Minimally Invasive Surgical (MIS) Fusion of the Sacroiliac Joint (SIJ); Effective 10/10/2019
12. Palmetto GBA LCD L39025 - Minimally Invasive Surgical (MIS) Fusion of the Sacroiliac Joint (SIJ); Effective 7/17/2022
13. Palmetto GBA LCA A58739- Billing and Coding: Minimally Invasive Surgical (MIS) Fusion of the Sacroiliac Joint (SIJ); Effective 7/17/2022; Revised 01/01/2023
14. Wisconsin Physicians Service Insurance Corporation LCD L36000- Percutaneous minimally invasive fusion/stabilization of the sacroiliac joint for the treatment of back pain; Effective 12/17/2015; revised 06/30/2022
15. Wisconsin Physicians Service Insurance Corporation LCA A57596- Billing and Coding: Percutaneous minimally invasive fusion/stabilization of the sacroiliac joint for the treatment of back pain; Effective 11/01/2019; revised 06/30/2022