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Insurance Coverage for Sacroiliac Joint Fusion

natasha_jaxnnatasha_jax Posts: 2
Does anyone have any information about Medicare adding coverage for minimally invasive fusion surgery of the S-I joint ("SIJ")?

For the last 4+ years, I have been appealing the denial by Anthem Blue Cross for SIJ fusion (using the SI-LOK system developed by Globus Medical). The procedure is unlike other spinal fusions. For example, I am fused from C3 to T1 (with titanium plate, 9 screws, donor bone grafts). These were performed first at C3-4 and C4-5; then extended 3 more levels to T1 following a car accident 8 months post-op. Each procedure involved a 4-5 hour surgery and 5 days in the hospital. By contrast, the minimally invasive SIJ fusion is done through a small incision (1" to 1-1/2") on the side of your butt cheek & the surgeon places 3 pins into the joint, with bone grafts. It takes about an hour. Initially, patients were kept overnight for unilateral SIJ fusion and two nights for bilateral. As techniques improved, hospital stays were reduced to one night for either. And according to my surgeon, if you are "gritty" and your surgery is performed early in the day, some patients are released later the same day.

With all that said, when my surgery request was first sent to Anthem for authorization, approval was anticipated based on the number of past approvals and also because I had numerous objective findings -- all confirmed by MRI, diagnostic injections, second opinion from a reputable neurosurgeon at UCSF. In fact, many Anthem patients with symptoms less severe than mine were getting approvals for SIJ fusion. Back then in 2010, Anthem's policy ("EOC") was silent as to SIJ fusions. Denials were based on the wholesale, rubber stamp reason we often see, i.e., "this procedure is considered to be experimental and investigational." It wasn't until April 2012 that Anthem adopted specific language in its EOC which provides coverage for SIJ fusion(s) under one or more of the following conditions:

(1) Fracture
(2) Sepsis
(3) Tumor
(4) Failure of prior arthrodesis above the SIJ

As so many of us here know, there are other reasons for SIJ disruption and the resultant debilitating and disabling pain. In my case, I have been told that my SIJ is "shredded" and so severely disrupted that therapeutic injections will not help. This was confirmed twice when the medication injected into the joint leaked down the inside of my leg and left me completely numb from the groin to my ankle, unable to walk for 8-10 hours while the Novocain wore off. This leaking is called "extravasation." Likewise, the cortisone injected into the joint leaked out, providing no relief whatsoever.

But moving along to coverage issues, I heard that once Medicare provides coverage for a specific condition, then private-pay carriers follow suit. After going through years of internal appeals within Anthem (as required by the policy), an administrative trial, etc., I am now at the point where I have to decide whether to pursue this matter in the Superior Court. Pursuant to Anthem's policy, an insured cannot file suit against Anthem until you have exhausted all of your administrative remedies under the policy. Anthem drags out this process for so long that I believe Anthem hopes its insureds will just give up and go away. According to my surgeon, no other patient within their group has ever taken an appeal this far through the process.

I am interested in hearing from any of you who have been involved in litigation against Anthem for denial of coverage for surgery/fusion of the SIJ -- or from anyone is familiar with this new Medicare policy that provides coverage for the newer, minimally invasive SIJ fusions (such as SI-LOK or iFuse, etc.)

Also, is it customary for private insurers, such as Anthem ("the Blues") or United Healthcare, et al., to adopt the same coverage allowances as Medicare? If you can provide a link to any substantive decisions or provisions by Medicare that have, or will, go into effect in 2015, I will be eternally grateful. I have researched this for hours and have been unable to find anything specific to approval of SIJ fusions for conditions beyond those already mentioned.

Thank you for reading through this. Any information will be greatly appreciated!


This is the type of information you need to call your Insurance company about. Different areas use different medical billing codes. Medicare has one set of guidelines, other Insurance companies have others.
So much depends on how it is billed by the hospital. Your first call should be to Medicare to discuss the options and found out from the Hospital what are the exact billing codes for the surgery
Ron DiLauro


  • Lisa JoyLLisa Joy KentuckyPosts: 21
    edited 04/15/2015 - 10:47 AM

    No luck here either and we've been fighting with Anthem since January 2014, although I've been in serious pain since 2009. I've had 2 surgeons and 2 pain docs agree it's my si joints and all of my symptoms, tests, CAT scans prove it. When I had my injections I also had leaking on both sides and the first surgeon said that's the best possible thing because it wouldn't leak if they weren't so far apart. My second surgeon, the one I'm with now, says he's never seen signs joints as far apart as mine are and it frustrates him that insurance won't approve. We are currently on our 9th appeal I think and still waiting for a decision. My husband has talked to attorneys but no one wants to represent us. He is currently drafting up something to put on Change dot org if we get denied again.

    I am confined to bed lying on my back with my knees propped up by pillows 23 hours a day. I am allowed but can barely sit up for one hour a day. I haven't been able to walk since Jan 2014 when my joints just finally said no more and I use a wheelchair in and out of my home. I take 2 very high powered controversial narcotics along with 2 blood pressure meds because my pain has caused high bp this year and several other drugs. I'm still crying a lot from the pain and can't understand why this is happening.

    We were told last year by my surgeon who works to help infuse with studies and to get insurance companies to approve that once the cost codes changed this year medicare was supposed to approve and usually private insurance follows suit. I'm not sure if medicare approved but Medicaid does now and that's a step in the right direction. My surgeon said I may have to wait until next year and hope they change their policy because right now they deny for every reason but the four reasons you listed and one of them I qualify for but because the si fusion wasn't done along with my spinal fusion it's not covered because I've had a fusion from S1 thru L4 with disc replacement.

    My surgeon has stated too that litigation for this is hard, expensive and drawn out but what are we to do. I'm at the point right now where I guess I will give up hoping to use the two degrees I just finished in 2013 and get my loans forgiven because it doesn't look promising. My surgeon also gave us info from a study done recently that states that si joint dysfunction is the third leading disease for pain and quality of life behind ALS and Parkinson's but still insurance wants to turn a blind eye to us.

    If you want to chat more or just need some encouragement private message me. My doctor has two other patients like me but for privacy reasons I don't know them and it would be nice to talk to someone whose walking or laying in my shoes.
    Lisa Joy

    Minor scoliosis, fusion of S1-L5-L4, discs replaced at L4/L5 and L5/S1 2007, spinal stenosis, degenerative disc disease, left and right SI Joint dysfunction with fractures along illiac crest, and vacuum phenomenon.
  • I have to tell you how reading your posts just filled me with such sadness for what
    you have both been through what a nightmare and continue to deal with
    such pain etc. I cannot imagine dealing with that pain as long as you have and the surgeries,
    injections plus then the
    insurance companies. I learned so much from reading your posts about the different
    surgeries they do and stuff that can happen. I am truly sorry and pray you find help
    and solutions for it all.
    I have been just close to loosing it at times about my pain from the
    SI joint which just got diagnosed. I feel stupid for asking you but did
    you ever have a hard time even getting the
    Doctors to test for it, did you go through that? How did they test
    you in the beginning any of the physical movement tests?
    I wondered can I ask you what were your symptoms when it first
    started? Did you experience burning, throbbing, ach and sitting so painful,
    bending, pain in your lower back, butt, hip, down the back of your leg,
    and into the groin? It is to the point with me I cannot get in the tub, sleep on
    and on. The pain feels like my skin has been peeled away and I cannot
    tolerate even my underwear pressing on my waist. Does that sound like
    what you feel or felt? Sorry I feel bad even asking with all of what you
    are dealing with. I take strong medications which just take the edge off.
    It is just so frustrating, they want me to start TP and the thought of moving
    anything or being touched sends me through the roof.
    Appreciate any in-put or advice you may have.
    You will be in my heart and hope for answers and help this pain is hell.
    Thanks Sherri
  • Lisa JoyLLisa Joy KentuckyPosts: 21
    I feel stupid for asking you but did
    you ever have a hard time even getting the
    Doctors to test for it, did you go through that? No, because it started two years after my lumbar fusion that I had a pain dr that knew right away.

    How did they test
    you in the beginning any of the physical movement tests? Yes, she did that test where they put you in positions and press and such. She also had me stand and pointed out that my hips were out of alignment and my scoliosis has gotten worse.

    I wondered can I ask you what were your symptoms when it first
    started? I was having problems sitting and lying on my sides. Then the pain started going down my legs and around my hips.

    Did you experience burning, throbbing, ach and sitting so painful,
    bending, pain in your lower back, butt, hip, down the back of your leg,
    and into the groin? Yes!!! To all. I cannot sit up for 30min and the pain starts, at one hour I have tears. I have not taken more than just a step from my wheelchair to the toilet in 15 months.

    It is to the point with me I cannot get in the tub, sleep on
    and on. The pain feels like my skin has been peeled away and I cannot
    tolerate even my underwear pressing on my waist. Does that sound like
    what you feel or felt? I wear only comfy yoga type pants that have no elastic and large legs like you can get at Wal-Mart. I cannot stand to even rub my own back, butt or hips it just hurts and jeans are out of the question.

    My pain started in 2009 but I really believe it was part of my original back pain that started in 2000 when I thought I was dealing with lumbar pain. In 2007 when I had my first back surgery I thought it would be fixed but I've never been pain free. Even after taking my 20mg oxycontin and 10mg oxycodone, I only get my pain down to a 6 or 7. I cry a lot and scream into my pillow. I live in our full finished basement where I can navigate my wheelchair better and have space to be and I can stay up all night without waking anyone and sleep when I can and not be woke up. I couldn't get my wheelchair in my bathroom upstairs and my bed is up higher than I can get on without a lot of effort.

    I'm sorry for your pain and I hope you find relief soon.
    Lisa Joy

    Minor scoliosis, fusion of S1-L5-L4, discs replaced at L4/L5 and L5/S1 2007, spinal stenosis, degenerative disc disease, left and right SI Joint dysfunction with fractures along illiac crest, and vacuum phenomenon.
  • Now I feel like I need to apologize to you, I have not had surgery and have
    not in any way went through the pain you have for that long. You are
    an incredible person like so many on here to deal with all of that.
    Like I said I have had the other back pain but this is a total ball game.
    It must be so painful to sit in a wheelchair at all, I cannot imagine.
    From what I read there are a lot of Doctor's who don't even check the SI-joint.
    I actually researched here found a video describing my exact symptoms
    and then some posts, that is how I convicted my Doctor to look at it.
    Reading your reply convinces me that I do have that problem and am going
    in the right direction. I too have not worn Levi's forever and wear nothing that
    touch's me if possible.
    I did get approval for another injection form Medicare thank God it does take
    some of the sensitivity away which I pray will make the therapy easier.
    I take 3 (20mg) oxycotine and 3 (endocet 10/325) a day and have got tolerant
    not helping much which sucks.
    Once again there are no words to express my thanks with all you are dealing with
    taking the time to help me.
    Take care of yourself and let us know how you are doing.
    Thanks Sherri
  • I have not logged into this site for several months because I was exhausted and just needed to step away for a while. However, today I received a "Registered Letter" from an insurance attorney who's supposed to have an extremely high rate of success when going against Anthem for denials of coverage. I contacted this lawyer at the request of my surgeon. I supplied his paralegal with a load of information. I waited five months before I heard back from them. I was then asked to put together a budget for what the cost would be for the SIJ fusion surgery. I submitted the budget and then waited another four months until today when I received a "Registered Letter" from this law firm. The letter was nothing more than a boilerplate CYA letter saying that they have decided not to take my case. They would not say why. However, I worked in the legal field for 25 years, and I know what a nonspecific "we-can't-take-your-case letter" means -- i.e., that the 25% they would get as a fee is not quite enough to cover their time and expense if they took the case. Because SIJ fusions can be performed as a minimally invasive procedure now, often requiring only an overnight stay in the hospital, the cost is way more than the average middle class budget can afford , but not expensive enough to make it worthwhile for a law firm to put its resources to work for you for a lousy $12,500.

    Reading through both of your stories breaks my heart. I have fought as much as I am able. Now that this attorney won't take my case because his 25% of the $50K fee I might win from Anthem isn't worth his time. Why did he have to take ten months to get back to me? I have found a fair amount of literature that suggests the cost of treating SIJ pain (expensive injections which must be done fluoroscopically; physical therapy; narcotic pain medications -- not to mention disability benefits -- far outweigh the cost of this now-minimally invasive fusion procedure. If you'd like to see what is involved, please go to the globus medical website and look at their video on the placement of the SI-LOK. To think that something so available when performed by a trained surgeon could change our quality of life is so close -- yet so unattainable --
  • skilletsskillet Cincinnati, OHPosts: 12
    I know this thread hasn't been active for almost a year, but for anyone who is still dealing with Blue Cross/Blue Shield (or any insurance company for that matter) refusing to pay for SI joint fixation/fusion surgery, I just received some VERY good information that can be used in your appeal/request for your insurance company to pay for this particular procedure.  I too was denied by BC/BS and ended up paying out of pocket for the surgery (I just had it done a couple days ago on 8/24/16).  I met someone who had it done the same day as me (who is actually a doctor himself) who was initially denied as well by BC/BS, but presented them with information that he found that resulted in them immediately reversing their denial and approving his procedure.  He is now going to help me do the same thing (hopefully) so I can try to get the decision reversed and get reimbursed.  If there is anyone out there who is in the same situation, I'll be happy to pass along everything I currently know and find out from this point forward.  If you want to chat, shoot me a private message on this forum as I probably won't regularly check this thread since it hasn't been active for quite a while.   
  • jmrineyjjmriney Terre Haute,INPosts: 1
    I just found out Friday 9-10-2016 that I was turned down but Anthem Blue cross for a si fusion.
    i injured my SI 6 years ago but recently found out I have connective tissue disorder and hypermobility which is  why my SI is not sable.  I have had no social life and live in constant pain. 
  • SavageSavage United StatesPosts: 5,427
    Hello jmriney !
    Welcome to Spine-Health
    Please click on link for helpful information!
    Spine-Health Moderator
    Please read my medical history at: Medical History

  • My right SI joint is currently hypermobile and causes me so much pain that I have to be bed ridden. This is following a 2002 surgery that fused my left SI joint and stabilized my right side with two screws. I have undergone 25 rehabilitation appointments , 7 injections in 2016 and to no avail. Pain rules my life. It has been recommended that I have a right SI joint fusion in December. It is my understanding that this minimally invasive surgery is experimental as indicated by Tricare for Life, therefore, it is no covered. My question is Why? Can anyone tell me if I can appeal their decision?
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