CPT 27280 · SI Fusion · Health Partners Plans / Jefferson Health Plans — PA HealthChoices
SI Fusion — Open at Health Partners Plans / Jefferson Health Plans — PA HealthChoices.
How Health Partners Plans / Jefferson Health Plans — PA HealthChoices approaches CPT 27280 (SI Fusion — Open) for prior-authorization review: at last review on 2026-05-06, the policy covers this code with prior authorization required.
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eviCore Spine Surgery — SI FusionCriteria summary
High-level themes from the Health Partners Plans / Jefferson Health Plans — PA HealthChoices policy of record for CPT 27280. Verbatim policy text and per-criterion analysis are available after sign-in.
- At least 24 weeks of conservative care typically required.
- Imaging concordance documentation required.
- Prior Diagnostic SI injection with ≥75% relief documentation required (typically with ≥75% relief).
Source: eviCore by Evernorth — Spine Surgery Clinical Guidelines (HPP/Jefferson MSK Spine Surgery Program)
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