Coverage of Conditions and Treatments (Coverage Decisions)
Use this lookup tool to determine coverage decisions, or if prior authorization is needed for the treatment or condition. Note: For Self-insured employer claims, you must contact the employer or their claims administrator.
List also available in PDF format.
See Treatment Guidelines and Resources for additional information.
(Effective date: September 1 2019; Last updated: September 2021)
Sacroiliac (SI) joint fusion is a surgical treatment used to address pain that originates from the joint between bones in the spine and hip (sacrum and ilium). SI joint fusion can be performed as an open procedure or as a minimally invasive procedure. It is unproven that SI joint fusion is superior to conservative management for chronic sacroiliac joint pain related to degenerative sacroiliitis and/or sacroiliac joint dysfunction, either de novo or after failed previous spinal surgery, in terms of safety, effectiveness or cost-effectiveness.
In adults, 18 years old and older, with chronic sacroiliac joint pain related to degenerative sacroiliitis and/or sacroiliac joint dysfunction, minimally invasive and open sacroiliac joint fusion procedures are not covered benefits.
Note: The scope of this decision does not apply to the following:*
- Low back pain of other etiology (g., radiculopathy, neurogenic claudication), sacroiliac joint pain related to recent major trauma or fracture, infection, cancer, or sacroiliitis associated with inflammatory arthropathies.
- Sacroiliac joint fusion revision surgery
The decision is based on the Health Technology Clinical Committee (HTCC) coverage determination finalized on May 17, 2019 and the re-review in July 2021. The committee’s determination, based on the most recent systematic review of the evidence on safety, efficacy and cost-effectiveness, is that SI joint fusion is not a covered benefit. Complete information on this HTCC determination is available here: What we're working on | Washington State Health Care Authority.
In adopting this HTCC coverage determination, the Department has concluded that the determination does not conflict with any state statute. Any coverage for investigational treatment would be considered per WAC 296-20-02850. Any coverage for health technologies that have a FDA Humanitarian Device Exemption status would be considered per RCW 70.14.120 (1) (b).
*For conditions that are out of scope, please refer to the Lumbar Spine Treatment Guideline for covered conditions and surgery criteria.