UnitedHealthcare (Commercial) · sacroiliac joint fusion

Dot phrase

Self-contained narrative A&P attestation. `***` = fill-in. Maps to UHC 2026T0621N (Sacroiliac Joint Interventions). UHC's public policy enumerates covered CATEGORIES only; the quantitative gates live in licensed InterQual (incl. a UHG Client-Defined custom set) and are NOT public.

.SIFUSIONUHC

Assessment: *** — sacroiliac joint pain on the *** side, supported by examination and
imaging: *** . UHC's public policy does not enumerate diagnostic criteria; they reside in
InterQual.

Medical necessity per UHC 2026T0621N, whose quantitative gates sit in gated InterQual: the
covered category here is minimally invasive SI joint fusion with a Titanium Triangular
Implant system (open SI joint fusion is a separate covered category, also per InterQual);
fusion with any other device, or for any other indication, is unproven and not covered.
Diagnostic SI joint block(s) were performed *** , with the actual dates and percentage relief
documented — UHC publishes no relief threshold. Provocative testing: *** , with each maneuver
and result documented — UHC publishes no required count. Conservative care: *** , with
modalities and dates documented — the public policy states no required duration. No sacral
lateral branch nerve block (64451) is billed or planned as a diagnostic step before RFA.

Plan: MIS sacroiliac joint fusion with a Titanium Triangular Implant system on the *** side,
CPT 27279. Risks, benefits, and alternatives discussed; consent obtained.

Where this payor diverges from the Medicare baseline

• device line (Titanium Triangular Implant system only; open fusion separate category)
• gates line (block %, provocative-test count, conservative duration delegated to gated InterQual)
• exclusion (sacral lateral branch blocks as diagnostic-before-RFA)

Cautions

• [!] Quantitative gates delegated to gated InterQual (incl. SI Joint Fusion Custom UHG criteria) — CONFIRM the actual thresholds with UM/billing. The InterQual-typical patterns (UNVERIFIED) are TWO image-guided intra-articular blocks EACH >=75%, and ~3 of 5 provocative tests positive; do not chart them as though UHC published them. Coding: 27279 = MIS transfixing device; 27278 = intra-articular without cortical piercing; 27280 = open arthrodesis. Sacral lateral branch blocks (64451) before RFA are not covered. Prior auth not stated in-policy — governed by a separate UHC PA list. SI injections are also subject to site-of-service review (separate policy). Regenerate if `uhc-commercial-si-fusion.md` `version` advances past `source_version`.