Priority Health (Michigan) updated its Lumbar Fusion Medical Policy to cover for SI-BONE's minimally invasive sacroiliac joint fusion procedure.
The procedure may now be considered medically necessary for policy holders with SI joint disruptions and degenerative sacroiliitis. Priority Health is the third largest commercial payer in Michigan and covers more than 500,000 lives.
"The growing body of clinical evidence and positive coverage policies, like that coming from Priority Health, once again confirm that the procedure represents an accepted standard of care in the medical community," said SI-BONE Vice President of Health Outcomes and Reimbursement Michael Mydra.
Two Medicare Administrative Contractors — Novitas Solutions and Palmetto GBA — announced coverage for MIS SI joint fusion earlier this year. Clinical studies show SI join is the pain generator in up to 22 percent of low back pain patients, with that number increased to 43 percent to 61 percent of symptomatic post-lumbar fusions.
SI-BONE gained FDA clearance for its iFUSE system in 2008 and several studies showing the procedure's effectiveness are covered in the literature. In a retrospective report of 263 patients at seven different sites, researchers compared open and minimally invasive SI joint fusions. The patients who underwent MIS SI joint fusion with iFuse had greater pain relief and better perioperative measures. The operative time was also reduced from 163 minutes in the open group to 70 minutes in the MIS group. The MIS group also had a shorter length of stay at the hospital — 1.3 days compared to 5.1 days for the open group. Finally, complication rate was lower for the MIS group, at 3.5 percent compared to 44 percent in the open group.
Another company focusing on SI joint procedures — Zyga Technology — enrolled its first patient in a clinical study for the SImmetry Sacroiliac Joint Fusion System in June after the company received an FDA clearance for the system in March 2013. "Clinical studies such as SAIF are critical to demonstrate the empirical value of sacroiliac joint fusion," said Noel D. Goldthwaite, MD, who performed the surgery for the study.
The American Medical Association announced the procedure would transition to a Category I CPT code effective Jan. 1, 2015.