Medicare, most Medicaid, and some commercial health plans provide coverage for minimally invasive sacroiliac (SI) joint fusion procedures. Your plan may require a written authorization prior to surgery. If your plan approves the request, an approval letter from your plan will be provided to you and your surgeon.
How to Find Out Whether You're Covered for iFuse
To determine whether minimally invasive SI joint fusion is covered under your health plan:
- Review your health plan’s website, read your plan's policy manual, or request your employer’s Summary of Benefits and Coverage document; look for minimally invasive SI joint fusion.
- Don't see it listed? Don't give up yet. Call your health plan to find out where you can find what's covered on your plan’s website or request a copy of your policy to be mailed to you.
- If your policy does not mention it, contact your insurance plan’s Member Customer Service Department to ask if the procedure (minimally invasive SI joint fusion) is covered under your plan. If it is, ask about the specific steps you need to take to initiate a prior authorization request.
SI Joint Fusion Insurance Authorization Checklist
Nationally, some government and private insurance plans reimburse for minimally invasive SI joint fusion, many on a case-by-case basis. A written prior authorization is recommended prior to surgery to verify coverage and benefits for the procedure.
Here is a checklist of items to include in a request for prior authorization. Ensure that your surgeon has copies of these documents to initiate the request:
- Your surgeon will complete a letter of medical necessity including your diagnoses, your proposed surgery date, and why the procedure is appropriate to treat your condition.
- Prior Authorization Form, available from your plan (if applicable).
- Chart notes related to your SI joint condition and your surgeon’s recommendation for surgery, including documentation of tried and failed treatments to resolve your SI joint condition, such as physical therapy, current medications related to the condition, and pain relief from therapeutic SI joint injection(s).
- Imaging studies (i.e., pelvis, hip, and/or lumbar spine). These may include x-rays, CT scans or MRI.
- Physician clinic notes from other providers who have treated or are treating you for the condition. This may include your PCP, physical therapist, and pain management physician.
- Peer-reviewed clinical studies to support the safety and efficacy of minimally invasive SI joint fusion procedures.
- Professional medical society recommendations or policies on patient selection of SI joint fusion (see NASS and ISASS).
Contact SI-BONE’s Reimbursement Support Team for patient insurance coverage support (PICS) information by phone 800-710-8511 or email PICS@si-bone.com.