CPT 0200T · SI Fusion · California Medicaid (Medi-Cal)
Sacroplasty — Unilateral at California Medicaid (Medi-Cal).
How California Medicaid (Medi-Cal) approaches CPT 0200T (Sacroplasty — Unilateral) for prior-authorization review: at last review on 2026-05-06, the policy covers this code with prior authorization required.
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Criteria summary
High-level themes from the California Medicaid (Medi-Cal) policy of record for CPT 0200T. Verbatim policy text and per-criterion analysis are available after sign-in.
- At least 12 weeks of conservative care typically required.
- Imaging concordance documentation required.
- Prior SI joint injection documentation required (typically with ≥50% relief).
Source: California Medicaid (Medi-Cal) Coverage for Orthopedic Procedures
See the full California Medicaid (Medi-Cal) criteria.
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