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Anthem Blue Cross Blue Shield / Elevance (Commercial) · sacroiliac joint fusion

v2verified 2026-07-24manual-pull source

✓ conditional · commercial

Criteria checklist

0 of 9 ticked
Indications
  • enumerated: yes
  • covered:
      • name: SI-joint pain confirmed as the primary pain generator
      • criteria:
        • approach: transiliac/lateral with an FDA-approved STRUCTURAL fixation (transfixation) device
        • pain duration function: >=6 months interfering with function; VAS >=5 AND ODI >=30
        • pain pattern: unilateral, caudal to L5, over posterior SI; POSITIVE Fortin finger test; no equal-severity tenderness elsewhere
        • imaging: SI CT/MRI excluding tumor/infection/inflammatory arthropathy; AP pelvis r/o hip; lumbar CT/MRI r/o neural compression; SI imaging showing injury/degeneration
  • investigational:
    • non-transfixing / joint-distraction-only constructs; POSTERIOR-approach intra-articular allograft/device
    • SI pain from infection, fracture, tumor, acute traumatic instability, or correlating neural compression
    • somatoform/fibromyalgia/generalized pain; ankylosing spondylitis or RA
Documented pathology (objective basis)required
Conservative care
  • required: yes
  • min duration months: 6
  • must include: a trial of >=1 therapeutic intra-articular SI corticosteroid injection
  • satisfied by:
    • failed >=6 months incl. SI steroid injection
    • contraindicated
  • modalities named:
    • NSAIDs / medication optimization
    • activity modification
    • physician-supervised active physical therapy
Trial
  • required: no
  • min duration days: not stated in the policy
  • success criteria: not stated in the policy
  • threshold is binding: no
Psychological evaluation
  • required: no
  • must clear: no
  • note posture: not required (generalized/behavioral pain conditions are exclusions)
Diagnostic block (SI joint)
  • required before: MIS SI fusion
  • count: 2
  • relief threshold pct: 75
  • image guided: fluoroscopy or CT, contrast-enhanced, intra-articular
Provocative tests
  • required: yes
  • min positive: 3
  • of: 7
  • examples:
    • long ligament
    • FABER/Patrick
    • active SLR
    • compression
    • distraction
    • thigh thrust
    • Gaenslen
Quantity limits
  • applies: yes
  • revision only for:
    • pseudarthrosis
    • symptomatic malposition with foraminal impingement
    • device infection
    • implant fracture/loosening
CPT cautionCPT 2026 descriptors (printed in the archived Carelon PDF p11): 27279 = transarticular and/or intra-articular device(s) PIERCING the ilium/sacrum cortices — the lateral transfixing construct Carelon COVERS; 27278 = intra-articular device(s) WITHOUT cortical piercing — the posterior/allograft-style construct Carelon EXCLUDES; 27280 = OPEN arthrodesis (unchanged; never bill a percutaneous procedure as 27280).
Payor-specific notes

Carelon (Anthem) SI fusion criteria require a transiliac/LATERAL transfixation device, TWO separate image-guided intra-articular SI blocks each >=75% (vs Medicare's single block), >=3 of 7 provocative tests, quantified VAS >=5 AND ODI >=30, a positive Fortin finger test, and a named pelvis/hip/lumbar imaging workup, after >=6 months conservative care that INCLUDES a therapeutic SI steroid injection. Posterior/intra-articular non-transfixing constructs are excluded — those bill CPT 27278 (intra-articular, no cortical piercing); the covered lateral transfixing construct bills 27279. From the actual fetched Carelon PDF.

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Dot phrase

Self-contained narrative A&P attestation. `***` = fill-in. Maps to Carelon MSK05 (Sacroiliac Joint Fusion), UM delegated by Anthem/Elevance. Two blocks, quantified scores, and the SI steroid injection inside the conservative window are the cell — document each.

.SIFUSIONANTHEM
.SIFUSIONANTHEM

Assessment: *** — sacroiliac joint pain on the *** side, confirmed as the primary pain
generator: unilateral, caudal to L5, over the posterior SI joint, with no equal-severity
tenderness elsewhere and a POSITIVE Fortin finger test. Pain has interfered with function for
>=6 months, with VAS >=5 (***) AND ODI >=30 (***). The imaging workup comprises SI CT/MRI
excluding tumor, infection, and inflammatory arthropathy while showing injury or degeneration
(***), an AP pelvis film ruling out hip pathology (***), and lumbar CT/MRI ruling out neural
compression (***).

Medical necessity per Carelon MSK05 (Sacroiliac Joint Fusion): provocative testing is positive
on *** of the long ligament, FABER/Patrick, active straight-leg raise, compression,
distraction, thigh thrust, and Gaenslen maneuvers — >=3 of 7 required. TWO separate
image-guided (fluoroscopy or CT), contrast-enhanced intra-articular SI joint blocks on ***
and *** each gave >=75% relief of the primary pain. Conservative care has failed over >=6
months, or was contraindicated, and included at least one therapeutic intra-articular SI
corticosteroid injection: *** (NSAIDs and medication optimization, activity modification, and
physician-supervised active physical therapy). The exclusions are absent: no infection,
fracture, tumor, or acute traumatic instability; no correlating neural compression; no
somatoform disorder, fibromyalgia, or generalized pain disorder; and no ankylosing
spondylitis or rheumatoid arthritis.

Plan: MIS sacroiliac joint fusion on the *** side via a transiliac/LATERAL approach with an
FDA-approved structural transfixation device whose implant PIERCES the ilium and sacrum
cortices — billed CPT 27279. Risks, benefits, and alternatives discussed; consent obtained.

Where this payor diverges from the Medicare baseline

  • diagnosis line (VAS >=5 + ODI >=30, positive Fortin, named imaging workup)
  • diagnostic-block line (TWO blocks, EACH >=75%)
  • conservative-care line (>=6 mo incl. therapeutic SI steroid injection)
  • device line (lateral transfixing 27279 covered; posterior non-piercing 27278 excluded)

Cautions

  • Posterior / intra-articular non-piercing constructs (CPT 27278) are NOT covered, and 27280 is OPEN arthrodesis — never bill a percutaneous procedure as 27280. Carelon prior auth (Medical Benefits Management). Revision covered only for pseudarthrosis, symptomatic malposition with foraminal impingement, device infection, or implant fracture/loosening. Regenerate if `anthem-commercial-si-fusion.md` `version` advances past `source_version`.

Prior-auth pathway

  • required: yes
  • pathway: Carelon Medical Benefits Management

Provenance

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Change history

  • 2026-07-24anthem/si-fusion: re-archive Carelon SIJ PDF (2026-01-29 reaffirmation) + update source_hash; diff = General-Clinical-Guideline boilerplate only, SI-fusion criteria unchanged (non-material, no version bump); last_verified 2026-07-24 9dd6c119c5
  • 2026-07-23si-fusion/anthem v2: cpt_caution had 27278/27279 reversed — correct per source PDF + CPT 2026 2641d29362
  • 2026-06-30Archive commercial source PDFs into sources/ + wire source_file/source_hash c5466694c8
  • 2026-06-28Add commercial SI Joint Fusion cells: Anthem, UHC, Cigna 0b3dab6dcb