SAN JOSE, Calif., Nov. 2, 2015 /PRNewswire/ — SI-BONE, Inc., a medical device company that pioneered the use of the iFuse Implant System®, a minimally invasive surgical (MIS) device indicated for fusion for certain disorders of the sacroiliac (SI) joint, announced that the Centers for Medicare & Medicaid Services (CMS) has issued its 2016 Hospital Outpatient Prospective Payment System (HOPPS) payment recommendation for MIS SI joint fusion that provides an increased outpatient payment when billing CPT 27279 from $9,266 to$10,538. The proposed payment represents an increase of $1,272 or 14% over the current payment amount. The new payment will become effective January 1, 2016.
In addition to the 2016 HOPPS payment, CMS also announced in their 2016 Medicare Physician Fee Schedule (MPFS) an increase in the physician reimbursement for MIS SI joint fusion procedures when billing CPT 27279 from the current national average of $577 to$722, a 25% increase, also effective January 1, 2016.
“With increased reimbursement for both the surgeon and facility, CMS continues to recognize the increasing value of MIS SI joint fusion,” said Michael Mydra, Vice President of Health Outcomes & Reimbursement at SI-BONE. “We believe that the iFuse Implant System fits strategically with the overall goals of the Affordable Care Act (ACA) by providing a safe, effective, and cost beneficial solution for the treatment of low back pain due to degenerative sacroiliitis and SI joint disruption.” 
In addition to the 2016 hospital outpatient and physician payment increases for MIS SI joint fusion, Medicare Administrative Contractor (MAC) Wisconsin Physician Services (WPS), covering the five states of Iowa, Indiana, Kansas, Michigan, Missouri and Nebraska, published a positive local coverage determination (LCD) that provides coverage beginning December 17. The decision by WPS to establish coverage for the procedure was based on a robust body of clinical evidence, over 95% of which is based on SI-BONE’s iFuse Implant System, that shows significant reduction in pain and improvement in quality of life in patients with SI joint dysfunction due to degenerative sacroiliitis or SI joint disruption.
Also, two additional MACs have released positive draft LCDs for MIS SI joint fusion. The first is National Government Services (NGS) covering ten states including Connecticut, Illinois, Massachusetts, Maine, Minnesota, New Hampshire, New York, Rhode Island, Vermontand Wisconsin and the second is CGS Administrators (CGS) which covers Ohio and Kentucky.
Upon finalization of the draft LCDs for NGS and CGS, 49 out of 50 states will cover MIS SI joint fusion providing coverage for 48 million Medicare beneficiaries in the United States.
“Once these 3 MACs implement coverage, seven of the eight MACs will have positive coverage for MIS SI joint fusion for over 98% of Medicare beneficiaries in the United States. We believe that the clinical and economic evidence supporting the iFuse Implant System as a safe and effective treatment for patients suffering from degenerative sacroiliitis or SI joint disruption has demonstrated that these patients deserve access to the procedure. We look forward to continuing our work to ensure that all patients have access to this important treatment option,” said Jeffrey Dunn, President and CEO of SI-BONE.
About SI-BONE, Inc.
SI-BONE, Inc. (San Jose, California) is the leading sacroiliac joint medical device company dedicated to the development of tools and products for patients with low back issues related to certain SI joint disorders. The company develops, manufactures and markets minimally invasive products for patients with these disorders. SI-BONE, Inc. received original 510(k) clearance in November 2008 from the Food and Drug Administration (FDA) to market its iFuse Implant System. The CE mark for European commercialization was obtained in November 2010.
The iFuse Implant System is a minimally invasive surgical option that uses titanium implants coated with a porous, titanium plasma spray (TPS) that acts as an interference surface, designed to help decrease implant motion, provide immediate fixation and allow for biological fixation to support long term fusion. The iFuse Implant System is intended for sacroiliac fusion for conditions including sacroiliac joint dysfunction that is a direct result of sacroiliac joint disruption and degenerative sacroiliitis. This includes conditions whose symptoms began during pregnancy or in the peripartum period and have persisted postpartum for more than 6 months. There are potential risks associated with the iFuse Implant System. It may not be appropriate for all patients and all patients may not benefit. For information about the risks, visit: www.si-bone.com/risks.