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You asked about SI joint fusion (MIS). HumanaChoice (Medicare Advantage, PPO) is governed by a framework cell — read the per-procedure line inside it and the embedded Traditional-Medicare criteria below.

HumanaChoice (Medicare Advantage, PPO) · all interventional pain

v1verified 2026-07-24needs re-verificationmanual-pull source

✓ conditional · medicare advantage

Criteria checklist

0 of 1 ticked
Indications
  • enumerated: no
  • description: HumanaChoice (PPO MA) applies the Traditional Medicare coverage FLOOR. NCD/LCD procedures use the corresponding `medicare-in-ky-*` criteria + Humana MA PA (cannot be more restrictive). For R&N procedures (Intracept, ReActiv8, endoscopic), the plan may apply its own internal criteria — pull the policy. PPO: out-of-network allowed at higher cost-share; same medical-necessity floor.
Payor-specific notes

POINTER cell. Same model as Humana Gold Plus but the PPO product (HumanaChoice) — Gold ≠ Choice (HMO vs PPO; the medical-necessity floor is identical, network/cost-share differ). Criteria = the Traditional Medicare cell per procedure + Humana MA PA; internal criteria only for R&N procedures. Plan PA vendor/process not independently verified (needs_reverification).

Ticks are a documentation aid — nothing is stored; they reset on reload.

Prior-auth pathway

  • required: yes
  • pathway: Humana MA prior authorization (MSK/spine often Cohere Health — confirm)

Provenance

  • authority:
    • type: medicare_advantage
    • floor: Traditional Medicare NCD/LCD per procedure — see policies/<procedure>/medicare-in-ky-*.md
    • plan um: Humana MA prior authorization / utilization management (MSK/spine PA often via Cohere Health — confirm)
    • applies because: Per CMS-4201-F (2024) / 42 CFR 422.101, MA must follow Traditional Medicare coverage criteria where an NCD/LCD fully establishes them; plan internal criteria only where Medicare is silent (R&N procedures)
  • source: https://www.ecfr.gov/current/title-42/section-422.101
  • effective: 2024-01-01 · payor last reviewed: — · we verified: 2026-07-24 · v1

Report an issue with this cell

Change history

  • 2026-07-24framework cells (MA x3, Medicaid IN/KY, VA): re-reviewed regulatory basis 2026-07-24 (42 CFR 422.101/CMS-4201-F, 405 IAC Art.5, KY KAR 907:3:130, 38 CFR 17.38(b) all current); plan/state-specific operational details (MA PA vendor, Medicaid interactive fee-schedule PA flags + MCO scopes, VA gated SEOC catalog/Optum manual/image-only CPG) remain gated -> needs_reverification kept; last_verified 2026-07-24 86bd4bd0b9
  • 2026-06-29Add Medicare Advantage pointer cells (Aetna, Humana Gold HMO, HumanaChoice PPO) 86a5e15292

Embedded cell · Traditional Medicare baseline

Medicare (Traditional Part A & B) — sacroiliac joint fusion

v2verified 2026-07-24

✓ conditional · medicare lcd

Criteria checklist

0 of 9 ticked
Indications
  • enumerated: yes
  • covered:
      • name: IN (WPS L36000) — SI joint pain, ALL of a-g
      • criteria:
        • conservative care failed: >=6 months intensive non-operative treatment: medication optimization + activity modification + active physical therapy
        • pain pattern: non-radiating, UNILATERAL pain caudal to L5, localized over the posterior SIJ, consistent with SIJ pain
        • palpation: localized tenderness over the posterior SIJ, WITHOUT similar-severity tenderness elsewhere (greater trochanter, lumbar spine, coccyx); no other obvious pain source
        • provocative tests: positive thigh thrust OR compression test, AND 2 of: Gaenslen's, distraction, Patrick's
        • no generalized pain: absence of generalized pain behavior (somatoform) or generalized pain disorders (fibromyalgia)
        • imaging workup: ALL: SIJ plain radiographs + CT or MRI (excludes destructive lesion/inflammatory arthropathy); ipsilateral hip plain radiographs (rules out OA); lumbar CT or MRI (rules out neural compression / other degenerative cause)
        • diagnostic blocks: TWO image-guided, contrast-enhanced SIJ injections on separate occasions, EACH with >=75% pain reduction for the expected duration of the anesthetic
      • name: KY (CGS L39802, selection per L39383) — MI arthrodesis WITH transfixation device, ALL required
      • criteria:
        • base selection: L39383 gates: moderate-severe pain over the SIJ (iliac crest to gluteal fold), >=3 months, below L5 without radiculopathy, no other cause on clinical/imaging assessment, >=4 weeks failed conservative therapy
        • provocative tests: >=3 positive of: FABER, Gaenslen, thigh thrust/posterior shear, SI compression, SI distraction, Yeoman
        • diagnostic block: >=1 diagnostic SIJI with >=75% relief (strict L39383 definition: sustained/constant for the duration of anesthetic AND steroid, same scale, pre/post/following-days measurements; max 2 diagnostic sessions)
        • therapeutic trial: >=1 THERAPEUTIC intra-articular corticosteroid SIJI with >=50% pain reduction for the expected duration of the injected agent
        • imaging workup: ALL: SIJ plain radiographs + CT or MRI (excludes destructive lesion, fracture, traumatic instability, inflammatory arthropathy); pelvis AP radiograph (rules out hip pathology); lumbar CT or MRI (rules out neural compression)
        • care plan: ongoing care plan with active participation in rehab / home-exercise / functional-restoration program; no generalized pain behavior/disorders
  • investigational:
    • non-transfixation / intra-articular-only arthrodesis (CPT 27278, posterior allograft systems): NOT covered in either state — CGS text explicitly; WPS article A57596 lists only 27279
    • systemic arthropathy (ankylosing spondylitis, rheumatoid arthritis); infection, tumor, or fracture; acute traumatic SIJ instability (WPS limitations)
    • neural compression on MRI/CT correlating with symptoms, or another more likely pain source
    • generalized pain behavior (somatoform) or generalized pain disorders (fibromyalgia)
    • failing the state's diagnostic-injection gate (IN: two >=75% blocks; KY: one >=75% block + >=50% therapeutic trial)
Documented pathology (objective basis)required
Conservative care
  • required: yes
  • min duration months: 6
  • satisfied by:
    • IN: >=6 months intensive non-operative treatment failed
    • KY: >=3 months pain with >=4 weeks conservative therapy failed
  • modalities named:
    • medication optimization
    • activity modification
    • 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
Diagnostic block (SI joint)
  • required before: MIS SI fusion (27279)
  • relief threshold pct: 75
  • image guided: yes
  • IN requirement: TWO image-guided contrast-enhanced SIJ injections on separate occasions, each >=75% relief for the anesthetic's expected duration
  • KY requirement: >=1 diagnostic SIJI >=75% (strict sustained/constant definition, max 2 diagnostic sessions) PLUS >=1 therapeutic corticosteroid SIJI with >=50% relief for the agent's expected duration
Provocative tests
  • required: yes
  • min positive: 3
  • IN structure: thigh thrust OR compression test positive, PLUS 2 of: Gaenslen's, distraction, Patrick's (WPS L36000 d)
  • KY structure: >=3 of: FABER, Gaenslen, thigh thrust/posterior shear, SI compression, SI distraction, Yeoman (CGS L39383)
Quantity limits
  • applies: yes
  • per joint: one MIS fusion per SI joint
Device / waveformagnostic
Payor-specific notes

Governed by each state's MIS SI fusion LCD — WPS L36000 (IN) and CGS L39802 (KY, which delegates patient selection to L39383). The criteria are NOT harmonized; this cell records them per state (verified 2026-07-24 against all three LCD bodies + WPS article A57596, read directly from the MCD via browser). IN: 6-month intensive non-operative floor; unilateral non-radiating pain with SIJ palpation tenderness absent elsewhere; structured test battery (thigh thrust OR compression + 2 of Gaenslen/distraction/Patrick); 3-part imaging workup incl. ipsilateral hip films; TWO separate >=75% contrast-enhanced blocks. KY: >=3 months pain + >=4 weeks conservative therapy; >=3 of 6 tests (incl. Yeoman); ONE >=75% diagnostic block (strict sustained/constant definition, max 2 diagnostic sessions) PLUS one >=50% therapeutic corticosteroid SIJI trial; imaging workup incl. pelvis AP film; active rehab participation. 27278 / non-transfixation arthrodesis (posterior allograft systems) is NOT covered in either state: CGS L39802 says non-transfixation is not reasonable-and-necessary; WPS A57596 lists ONLY 27279. Note: CGS L39383 also deems SIJ RFA/denervation not reasonable-and-necessary (KY). Excludes systemic arthropathy (AS/RA), infection/tumor/fracture, acute traumatic instability, correlating neural compression, and generalized pain disorders.

Ticks are a documentation aid — nothing is stored; they reset on reload.

Dot phrase

Lean narrative A&P attestation. `***` = fill-in. Maps to WPS L36000 (IN) / CGS L39802+L39383 (KY), bodies verified 2026-07-24. **The criteria are NOT harmonized — use the block for the patient's state.**

.SIFUSIONMCARE
.SIFUSIONMCARE  [INDIANA / WPS L36000]

Assessment: *** — sacroiliac joint pain on the *** side: non-radiating, UNILATERAL, caudal to
L5, localized over the posterior SI joint, with localized SIJ tenderness on palpation and no
similar tenderness at the greater trochanter, lumbar spine, or coccyx.

Medical necessity per WPS LCD L36000: intensive conservative care has failed over >=6 MONTHS
— medication optimization, activity modification, and active physical therapy: *** .
Provocative testing is positive on [thigh thrust / compression] together with 2 of Gaenslen's,
distraction, and Patrick's: *** . There is no generalized pain behavior or disorder such as
somatoform disorder or fibromyalgia. Imaging shows SIJ radiographs and *** (CT/MRI) without
destructive lesion or inflammatory arthropathy, ipsilateral hip radiographs without
osteoarthritis, and lumbar *** (CT/MRI) without neural compression. TWO image-guided,
contrast-enhanced SIJ injections on *** and *** each gave >=75% relief for the anesthetic's
expected duration.

.SIFUSIONMCARE  [KENTUCKY / CGS L39802 + L39383]

Assessment: *** — moderate-to-severe sacroiliac joint pain on the *** side, localized over
the SI joint from the iliac crest to the gluteal fold, below L5, WITHOUT radiculopathy,
present >=3 months, with no other cause identified on clinical and imaging assessment.

Medical necessity per CGS LCD L39802 (selection per L39383): conservative therapy has failed
over >=4 weeks and the patient is actively participating in a rehabilitation, home-exercise,
or functional-restoration program. Provocative testing is positive on >=3 of FABER, Gaenslen,
thigh thrust / posterior shear, SI compression, SI distraction, and Yeoman: *** . A diagnostic
SIJ injection on *** gave >=75% sustained and constant relief for the duration of both the
anesthetic AND the steroid, measured on the same scale as baseline with pre-, post-, and
following-day measurements documented; a therapeutic corticosteroid SIJ injection on *** then
gave >=50% relief for the agent's expected duration. Imaging shows SIJ radiographs and ***
(CT/MRI) without destructive lesion, fracture, traumatic instability, or inflammatory
arthropathy, an AP pelvis radiograph without hip pathology, and lumbar *** (CT/MRI) without
neural compression.

Plan: Minimally invasive SI joint arthrodesis WITH a transfixing/transarticular device on the
*** side (CPT 27279), using an FDA-cleared implant. Risks, benefits, and alternatives
discussed; consent obtained.

Where this payor diverges from the Medicare baseline

  • per-state diagnostic-block gate (IN two >=75% blocks vs KY one block + therapeutic trial)
  • per-state conservative-care floor (6 mo vs 3 mo/4 wk)
  • per-state provocative-test battery

Cautions

  • 27279 ONLY in both states. 27278 / non-transfixation (posterior allograft) is NOT covered: CGS states it explicitly; WPS article A57596 lists only 27279. Regenerate if `medicare-in-ky-si-fusion.md` `version` advances past `source_version`.

Prior-auth pathway

  • required: no
  • verified: no
  • note: Not a verified OPD prior-auth category; confirm if furnished hospital-outpatient.

Provenance

  • authority:
    • type: lcd
    • title: Minimally invasive sacroiliac joint fusion / arthrodesis
    • lcds:
      • IN: L36000 (WPS, J8) — 'Percutaneous minimally invasive fusion/stabilization of the SI joint' — v21 eff 2024-06-27 (body verified via MCD browser pull 2026-07-24; 2026 revisions = formatting only)
      • KY: L39802 (CGS, J15) — 'Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ)' — v8 eff 2025-05-15 (body verified 2026-07-24; delegates patient selection to CGS L39383 'SIJ Injections and Procedures' v13 eff 2026-04-02, also verified)
    • applies because: WPS (IN) and CGS (KY) each publish an MIS SI fusion LCD; criteria are NOT harmonized — this cell records them per state
    • divergence note: Verified per-state divergences (2026-07-24): (1) Diagnostic gate — WPS: TWO image-guided contrast-enhanced SIJ injections on separate occasions, each >=75% relief; CGS: ONE diagnostic block >=75% (strict L39383 definition, max 2 diagnostic sessions) PLUS one THERAPEUTIC corticosteroid SIJI with >=50% relief for the agent's expected duration. (2) Conservative care — WPS: >=6 months intensive non-operative; CGS: >=3 months pain + >=4 weeks conservative therapy + active rehab participation. (3) Provocative tests — WPS structured: (thigh thrust OR compression) AND 2 of {Gaenslen, distraction, Patrick}; CGS: >=3 of {FABER, Gaenslen, thigh thrust/posterior shear, compression, distraction, Yeoman}. (4) CPT 27278/non-transfixation — NOT covered in either state: CGS text says non-transfixation arthrodesis is not reasonable-and-necessary; WPS article A57596 lists ONLY 27279. (5) WPS uniquely requires unilateral non-radiating pain + SIJ palpation tenderness absent elsewhere + ipsilateral hip radiographs; CGS uniquely requires pelvis AP radiograph.
    • billing articles:
      • A57596 (WPS, IN)
      • A59682 (CGS, KY)
  • source: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=36000&ver=21
  • effective: 2024-06-27 · payor last reviewed: 2026-05-21 · we verified: 2026-07-24 · v2