August 22, 2014
The ISASS Coding and Reimbursement Task Force has been busy addressing our membership's needs while advocating spine access (further projects are in the pipeline). Our past MIS SIJ Policy was created early as MIS SIJ was evolving. The current body of literature is now more robust and a timely educational update for ISASS & IASP membership and will appear in an upcoming issue of the International Journal of Spine Surgery.
It is my hope as Task Force Chair that this ISASS policy be additionally used at this opportune time to expeditiously respond or comment on HSCS e-comment deadline as lines are drawn in the sand (see below for details) Please review the attached which has been reviewed and edited by ISASS President Gunnar Andersson, MD, PhD and the members of the Coding and Reimbursement Task Force. This updated policy statement is available for your review at the link below on the IJSS website. For those in Vermont, North Dakota, Texas, Oklahoma, New Mexico, Montana and Illinois please use the links below to further fight your battles for coverage.
Morgan P. Lorio, MD, FACS
ISASS Coding and Reimbursement Task Force Chair
Attention ISASS members in Vermont, North Dakota, Texas, Oklahoma, New Mexico, Montana and Illinois:
To advocate for policy changes in your state, please follow these instructions. We apologize for this complex process, the BCBS website will not allow direct linking to certain web pages.
To View the Current BCBS Medical Policy, follow these instructions:
1. Visit this link in your web browser:
2. Click "Agree" on the pop-up window and then click on the "Active Policies - View All Policies" button.
3. Search through the listings until you find the "S" section and link for the document below:
Sacroiliac Joint Fusion or Stabilization
Sacroiliac joint (SIJ) fusion or stabilization for the treatment of back pain presumed to originate from the SIJ is considered experimental, investigational and unproven, including but not limited to percutaneous and minimally invasive techniques.
Similar to other structures in the spine, it is assumed that the sacroiliac joint (SIJ) may be a source of low back pain. In fact, prior to 1928, the SIJ was thought to be the most common cause of sciatica. In 1928, the role of the intervertebral disc was elucidated, and from that point forward, the SIJ received less research attention.
That document is the current BCBS Medical Policy (No Coverage) for SIJ Fusion. Once you have reviewed the current policy, click the following link to view the draft policy - note that the comment period ends on September 1, 2014:
The draft policy is currently: "TBD Document updated with literature review. Coverage unchanged. Rationale and References substantially revised."
There has been some activity with the Blues plans recently opening up their coverage decisions for SIJ for comment and reconsideration. Unfortunately, all of the policy updates still have the procedure listed as a non-covered benefit. The good news is that for the most part they have "attempted" to update their literature references. VT, ND, and HCSC (TX, OK, NM, MT,IL) just published draft policies for comment. HCSC is accepting comments next week on their updated policy. This may be an opportune time for the Society to comment on the policy. Surgeons in those states may want to comment.
To comment on the new draft policy and advocate for coverage by BCBS of Sacroiliac Joint Fusion or Stabilization in your State, click the link "Comment on this Policy" at the top-right of the web page.
In April ISASS informed various payers of updated in SIJ Fusion issues - Priority Health in Michigan read and responsed with the following (it is a start):
Priority Health (600,00 covered lives-aprox 12,000 employers) is going to begin covering SIJ fusions.
SI-BONE, Inc. Announces Positive Coverage Decision by Priority Health
First Commercial Positive Coverage Decision Adds to Prior Policies by Medicare (Novitas and Palmetto)
SAN JOSE, Calif., Aug. 21, 2014 /PRNewswire/ -- SI-BONE, Inc. (San Jose, California), a medical device company that pioneered the use of the iFuse Implant System,® a minimally invasive surgical (MIS) device indicated for fusion of the sacroiliac (SI) joint, announced that Priority Health (Michigan) published an update to its Lumbar Fusion Medical Policy No. 91590-R4 providing positive coverage for SI-BONE's MIS SI joint fusion procedure. The policy states that the fusion procedure, which employs the iFuse Implant System, may now be considered medically necessary for members with SI joint disruptions and degenerative sacroiliitis. [...]