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

.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.