Cigna Healthcare (Commercial) · sacroiliac joint fusion

Dot phrase

Self-contained narrative A&P attestation. `***` = fill-in. Maps to eviCore CMM-611 (Sacroiliac Joint Fusion or Stabilization), UM delegated by Cigna. Distinctive gates: the nicotine/cotinine requirement and the behavioral-health exclusions — document both.

.SIFUSIONCIGNA

Assessment: *** — lumbopelvic pain arising from the sacroiliac joint on the *** side,
localized to Fortin's point, caudal to L5, and interfering with activities of daily living.

Medical necessity per Cigna eviCore CMM-611: provocative testing is positive on *** of thigh
thrust, compression, Gaenslen, distraction, FABER/Patrick, and posterior provocation — >=3 of
6 required. TWO separate image-guided (fluoroscopy or CT) intra-articular SI joint injections
on *** and *** each gave >=75% relief. Conservative care has failed over >=6 consecutive
months, or was contraindicated, and included at least one therapeutic intra-articular SI
injection: *** (NSAIDs, medication optimization, activity modification, and
physician-supervised active physical therapy). The patient is nicotine-free, with cotinine
<=10 ng/mL or >=6 weeks of abstinence (***), and has no fibromyalgia, no somatoform disorder,
and no unmanaged behavioral-health condition.

Plan: MIS sacroiliac joint arthrodesis on the *** side with an implant that TRAVERSES and
TRANSFIXES the joint, CPT 27279, unilateral this date of service. Risks, benefits, and
alternatives discussed; consent obtained.

Where this payor diverges from the Medicare baseline

• diagnosis line (Fortin's point, caudal to L5, ADL interference)
• diagnostic-block line (TWO injections, EACH >=75%)
• conservative-care line (>=6 consecutive mo incl. therapeutic SI injection)
• behavioral/smoking line (cotinine gate; fibromyalgia/somatoform/BH exclusions)
• device line (must traverse + transfix)
• limit (no same-day bilateral)

Cautions

• Device exclusions: non-transfixing, joint-distraction-only, allograft-wedge, and non-metallic constructs are NOT covered. Open SI fusion is reserved for trauma, infection, tumor, long deformity constructs, or failed MIS — not for mechanical LBP / SI syndrome / degenerative SI joint. Same-day BILATERAL SI fusion is not medically necessary. Confirm the 2026 CPT mapping (27279 vs 27280) for the specific device used. eviCore/Evernorth prior auth. [!] Pending: CMM-611 successor effective 2026-08-04 (not yet in force) — re-verify criteria against the successor on/after that date. Regenerate if `cigna-commercial-si-fusion.md` `version` advances past `source_version`.