Diagnosis and Treatment of Sacroiliac Joint Pain

Description of Procedure or Service

Sacroiliac joint (SIJ) arthrography using fluoroscopic guidance with injection of an anesthetic has been explored as a diagnostic test for sacroiliac joint pain. Duplication of the patient’s pain pattern with the injection of contrast medium suggests a sacroiliac etiology, as does relief of chronic back pain with injection of local anesthetic. Treatment of sacroiliac joint pain with corticosteroids, radiofrequency ablation (RFA), stabilization, or minimally invasive sacroiliac joint fusion has also been explored.

Similar to other structures in the spine, it is assumed that the sacroiliac joint may be a source of low back pain. In fact, prior to 1928, the sacroiliac joint 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 sacroiliac joint received less research attention.

Research into sacroiliac joint pain has been plagued by lack of a criterion standard to measure its prevalence and against which various clinical examinations can be validated. For example, sacroiliac joint pain is typically without any consistent, demonstrable radiographic or laboratory features and most commonly exists in the setting of morphologically normal joints. Clinical tests for sacroiliac joint pain may include various movement tests, palpation to detect tenderness, and pain descriptions by the patient. Further confounding the study of the sacroiliac joint is that multiple structures, such as posterior facet joints and lumbar discs, may refer pain to the area surrounding the sacroiliac joint.

Because of inconsistent information obtained from history and physical examination, some have proposed the use of image-guided anesthetic injection into the sacroiliac joint for the diagnosis of sacroiliac joint pain. Treatments being investigated for sacroiliac joint pain include prolotherapy, corticosteroid injection, radiofrequency ablation, stabilization, and arthrodesis. Some procedures have been referred to as SIJ fusion but may be more appropriately called fixation due to little to no bridging bone on radiographs. Devices for SIJ fixation/fusion that promote bone ingrowth to fixate the implants include a triangular implant (iFuse Implant System) and cylindrical threaded devices (Rialto, SImmetry, Silex, SambaScrew, SI-LOK). Some devices also have a slot in the middle where autologous or allogeneic bone can be inserted. This added bone is intended to promote the fusion of the SIJ.

This policy does not address the treatment of sacroiliac joint pain due to infection, trauma or neoplasm.

Regulatory Status

A number of radiofrequency generators and probes have been cleared for marketing by the U.S. Food and Drug Administration (FDA) through the 510(k) process. In 2005, the SInergy® (Halyard; formerly Kimberly-Clark), a water-cooled single-use probe, was cleared by the FDA, listing the Baylis Pain Management Probe as a predicate device. The intended use is in conjunction with a radiofrequency generator to create radiofrequency lesions in nervous tissue. FDA product code: GXD, GXI.

A number of percutaneous or minimally invasive fixation/fusion devices have been cleared for marketing by FDA through the 510(k) process. They include the iFuse® Implant System and iFuse-3D™ Implant (SI Bone), the Rialto™ SI Joint Fusion System (Medtronic), SIJ-Fuse (Spine Frontier), the SImmetry® Sacroiliac Joint Fusion System (Zyga Technologies), Silex™ Sacroiliac Joint Fusion System (XTANT Medical), SambaScrew® and FIREBIRD SI Fusion System (Orthofix), and the SI-LOK® Sacroiliac Joint Fixation System (Globus Medical) and the SIimpact Sacroiliac Joint Fixation System (Life Spine). FDA product code: OUR.

Related Policies

Facet Joint Denervation

Epidural Steroid Injections for Back Pain

Sacroiliac Joint Fusion Vertebroplasty, Kyphoplasty, and Sacroplasty Percutaneous

Prolotherapy

***Note: This Medical Policy is complex and technical. For questions concerning the technical language and/or specific clinical indications for its use, please consult your physician.

Policy

BCBSNC will provide coverage for diagnosis and treatment of sacroiliac joint pain when it is determined to be medically necessary because the medical criteria and guidelines noted below are met.

Arthrography and radiofrequency denervation of the sacroiliac joint are considered investigational for all applications. BCBSNC does not provide coverage for investigational services or procedures.

Benefits Application

This medical policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this medical policy.

When diagnosis and treatment of sacroiliac joint pain is covered

Injection of anesthetic for diagnosing sacroiliac joint pain may be considered medically necessary when the following criteria have been met:

• Pain has failed to respond to 3 months of conservative management, which may consist of therapies such as nonsteroidal anti-inflammatory medications, acetaminophen, manipulation, physical therapy, and a home exercise program; AND
• Dual (controlled) diagnostic blocks with 2 anesthetic agents with differing duration of action are used; AND
• The injections are performed under imaging guidance

Injection of corticosteroid may be considered medically necessary for the treatment of sacroiliac joint pain when the following criteria have been met:

• Pain has failed to respond to 3 months of conservative management, which may consist of therapies such as nonsteroidal anti-inflammatory medications, acetaminophen, manipulation, physical therapy, and a home exercise program; AND
• The injection is performed under imaging guidance; AND
• No more than 3 injections are given in one year

When diagnosis and treatment of sacroiliac joint pain is not covered

Arthrography of the sacroiliac joint is considered investigational.

Radiofrequency denervation of the sacroiliac joint is considered investigational.

Policy Guidelines

Diagnostic

For individuals who have suspected SIJ pain who receive a diagnostic sacroiliac block, the evidence includes systematic reviews. Relevant outcomes are test validity, symptoms, functional outcomes, quality of life, medication use, and treatment-related morbidity. Current evidence is conflicting on the diagnostic utility of SIJ blocks. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Therapeutic

For individuals who have SIJ pain who receive therapeutic corticosteroid injections, the evidence includes systematic reviews, randomized controlled trials (RCTs) , and case series. Relevant outcomes are symptoms, functional outcomes, QOL, medication use, and treatment-related morbidity. In general, the literature on injection therapy of joints in the back is of poor quality. Results from from 1 RCT showed superiority over a sham control group, but 2 RCTs showed that therapeutic SIJ steroid injections were not as effective as other active treatments. Larger trials with rigorous designs and sufficient follow-up, preferably using sham injections, are needed to determine that the technology improves the net health outcome. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have SIJ pain who receive RFA, the evidence includes 6 RCTs using different radiofrequency applications and case series. Relevant outcomes are symptoms, functional outcomes, QOL, medication use, and treatment-related morbidity. Meta-analysis of available sham-controlled RCTs suggests that there may be a small effect of RFA on SIJ pain at short-term (1 to 3 months) follow-up. However, the RCTs of RFA have methodologic limitations, and there is limited data on the duration of the treatment effect. The single RCT with 6 and 12-month follow-up showed no significant benefit of RFA compared to an exercise control group at these time points. In addition, heterogeneity of RFA treatment techniques precludes generalizing results across different studies. For RFA with a cooled probe, 3 RCTs reported short-term benefits, but these are insufficient to determine the overall effect on health outcomes. An RCT on palisade RFA of the SIJ did not include a sham control. Another sham-controlled RCT showed no benefit from RFA. Further high-quality controlled trials are needed to compare this procedure in defined populations with sham control and alternative treatments. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have SIJ pain who receive SIJ fixation/fusion with a transiliac triangular implant, the evidence includes 2 nonblinded RCTs of minimally invasive fusion, prospective cohorts with more than 85% follow-up, and case series. Relevant outcomes are symptoms, functional outcomes, QOL, medication use, and treatment-related morbidity. Both RCTs have reported outcomes past 6 months, after which crossover was allowed. Both studies reported significantly greater reductions in visual analog scale pain scores and Oswestry Disability Index scores in SIJ fusion patients than in control groups. The reductions in pain and disability observed in the SIJ fusion group at 6 months were maintained out to 1 year compared with controls who had not crossed over. The RCTs were nonblinded without a placebo or an active control group. Prospective cohorts and case series with sample sizes ranging from 45 to 149 patients and low dropout rates (<15%) also showed reductions in pain and disability out to 5 years. The cohort studies and case series are consistent with the durability of treatment benefit. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have SIJ pain who receive SIJ fusion/fixation with an implant other than a transiliac triangular implant, the evidence includes 4 prospective cohort studies and retrospective case series. Relevant outcomes are symptoms, functional outcomes, QOL, medication use, and treatmentrelated morbidity. Three prospective cohorts were conducted with transiliac screws and the third with a device inserted through a posterior approach. No controlled studies were identified. Meta-analyses of the available prospective and retrospective studies indicate improvement in subjective outcomes from before surgery to follow-up, but with a possible difference in outcomes between the more well studied triangular transiliac implant and other implant designs and approaches. There is uncertainty in the health benefit of SIJ fusion/fixation with these implant designs. Therefore, controlled studies with a larger number of patients and longer follow-up are needed to evaluate these devices. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome. The American Society of Interventional Pain Physicians (2013) guidelines have been updated. The updated guidelines recommend the use of controlled SIJ blocks with placebo or controlled comparative local anesthetic block when indications are satisfied with suspicion of SIJ pain. A positive response to a joint block is considered to be at least a 75% improvement in pain or in the ability to perform previously painful movements.

Billing/Coding/Physician Documentation Information

This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.

Applicable codes: 27096, 27279, G0259, G0260, 64625

BCBSNC may request medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.

Scientific Background and Reference Sources

For guideline titled “Sacroiliac Joint Arthroscopy and Injection

BCBSA Medical Policy Reference Manual [Electronic Version]. 6.01.23, 2/1/10

Boswell MV, Trescot AM, Sukdeb D, et al. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician 2007; 10:7-111. Retrieved on July 20.2010 from http://www.ncbi.nlm.nih.gov/pubmed/17256025

Manchikanti L, Boswell MV, Singh V et al. Comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician 2009; 12(4):699-802.Retrieved on July 20, 2010 from http://www.ncbi.nlm.nih.gov/pubmed/19644537

Manchikanti L, Datta S, Derby R, et al. A critical review of the American Pain Society clinical practice guidelines for interventional techniques: part 1. Diagnostic interventions. Pain Physician. 2010 May-Jun;13(3):E141-74.Retrieved on July 20, 2010 from http://www.painphysicianjournal.com/linkout_vw.php?issn=1533-3159&vol=13&page=E141

Rupert MP, Lee M, Manchikanti L et al. Evaluation of sacroiliac joint interventions: a systematic appraisal of the literature. Pain Physician 2009; 12(2):399-418.Retrieved on July 20, 2010 from http://www.ncbi.nlm.nih.gov/pubmed/19305487

Senior Medical Director review 8/2010

Manchikanti L, Datta S, Gupta S et al. A critical review of the American Pain Society Clinical practice guidelines for interventional techniques: part 2. Therapeutic interventions. Pain Physician. 2010; 13(4):E215-64.

BCBSA Medical Policy Reference Manual [Electronic Version]. 6.01.23, 2/10/11

Specialty Matched Consultant Advisory Panel review 7/2011

For guideline titled “Diagnosis and Treatment of Sacroiliac Joint Pain”

BCBSA Medical Policy Reference Manual [Electronic Version]. 6.01.23, 2/9/12

Specialty Matched Consultant Advisory Panel review 7/2012

BCBSA Medical Policy Reference Manual [Electronic Version]. 6.01.23, 2/14/13

Specialty Matched Consultant Advisory Panel – 5/2013

BCBSA Medical Policy Reference Manual [Electronic Version]. 6.01.23, 5/22/14

Specialty Matched Consultant Advisory Panel – 5/2014

For policy titled “Diagnosis and Treatment of Sacroiliac Joint Pain”

BCBSA Medical Policy Reference Manual [Electronic Version]. 6.01.23, 4/23/15

Specialty Matched Consultant Advisory Panel – 5/2015

BCBSA Medical Policy Reference Manual [Electronic Version]. 6.01.23, 11/12/15

Specialty Matched Consultant Advisory Panel – 5/2016

BCBSA Medical Policy Reference Manual [Electronic Version]. 6.01.23, 8/11/16

BCBSA Medical Policy Reference Manual [Electronic Version]. 6.01.23, 10/13/16

BCBSA Medical Policy Reference Manual [Electronic Version]. 6.01.23, 12/14/2017

BCBSA Medical Policy Reference Manual [Electronic Version]. 6.01.23, 11/8/2018

Specialty Matched Consultant Advisory Panel – 04/2020

BCBSA Medical Policy Reference Manual [Electronic Version]. 6.01.23, 11/14/19

Manchikanti L, Abdi S, Atluri S, et al. An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain Physician. Apr 2013;16(2 Suppl): S49-283. PMID 23615883

BCBSA Medical Policy Reference Manual [Electronic Version]. 6.01.23, 11/12/2020

Specialty Matched Consultant Advisory Panel – 04/2021

Medical Director review 4/2021

Specialty Matched Consultant Advisory Panel – 04/2022

Medical Director review 4/2022

Specialty Matched Consultant Advisory Panel 04/2023

Medical Director review 4/2023

Specialty Matched Consultant Advisory Panel 04/2024

Medical Director review 4/2024

Policy Implementation/Update Information

For guideline titled “Sacroiliac Joint Arthroscopy and Injection

8/31/10 New Evidence Based Guideline implemented. Sacroiliac joint arthrography and/or injection are not recommended as treatment for sacroiliac pain. (mco)

4/26/11 References updated. No changes to guideline statements. (mco)

8/16/11 Specialty Matched Consultant Advisory Panel review 7/2011. No changes to guideline statements. (mco)

12/30/11 Deleted code 73542 from “Billing/Coding” section. (mco)

For guideline titled “Diagnosis and Treatment of Sacroiliac Joint Pain”

5/1/12 Guideline titled changed from “Sacroiliac Joint Arthroscopy and Injection” to “Diagnosis and Treatment of Sacroiliac Joint Pain.” Description section updated. “Not Recommended” section updated. The following statement added to the Evidence Based Guidelines: “Radiofrequency ablation of the sacroiliac joint is not recommended as a treatment for sacroiliac pain.” References updated. Medical Director review 4/2012. (mco)

5/15/12 Information regarding radiofrequency ablation of the sacroiliac joint deleted. Description section updated to include reference for BCBSNC policy titled, “Facet Joint Denervation.” Medical Director review 5/2012. (mco)

8/7/12 Specialty Matched Consultant Advisory Panel review 7/2012. No changes to guideline statements. (mco)

4/16/13 References updated. Added “Sacral Joint Fusion” as a related policy. (mco)

7/16/13 Specialty Matched Consultant Advisory Panel review 5/15/2013. No change to guideline. (btw)

1/28/14 Added HCPCS codes G0259 and G0260 to Billing/Coding section. (btw)

11/25/14 Reference added. Specialty Matched Consultant Advisory Panel review 5/27/2014. Guideline changed to may be appropriate for controlled diagnostic injections and for therapeutic injections with corticosteroid. Medical Director review. (sk)

For policy titled “Diagnosis and Treatment of Sacroiliac Joint Pain”

7/28/15 Evidence based guideline converted to corporate medical policy. Medical director review. Reference added. Specialty Matched Consultant Advisory Panel review 5/27/2015. Notification given 7/28/15 for policy effective date 10/1/15. (sk)

2/29/16 Reference added. Related policy added. Policy Guidelines updated. (sk)

7/1/16 Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 5/25/2016. (sk)

11/22/16 References added. Policy Guidelines updated. (sk)

6/30/17 Specialty Matched Consultant Advisory Panel review 4/26/2017. No change to policy statement. (an)

6/8/18 Codes 27096 and 27279 added to Billing/Coding section. Reference added. Specialty Matched Consultant Advisory Panel review 5/23/2018. No change to policy statement. (an)

4/30/19 Updated Description and Policy Guidelines sections. Deleted code 20552 from Billing/Coding section. Reference added. Specialty Matched Consultant Advisory Panel review 4/17/2019. (an)

4/28/20 References added. Policy guidelines updated. No change to policy statement. Specialty Matched Consultant Advisory Panel review 4/15/2020. (eel)

5/4/21 Updated Description and Policy Guidelines section. Code 64625 added to Billing/Coding section. Reference added. Specialty Matched Consultant Advisory Panel review 4/2021. Medical Director review 4/2021. (bb)

11/16/21 Correction made to Billing/Coding section. Added code 64625. (tt)

5/3/22 References added. Related policies updated. No change to policy statement. Specialty Matched Consultant Advisory Panel review 4/2022. (tt)

5/2/23 References added. Related policies and policy guidelines updated. No change to policy statement. Specialty Matched Consultant Advisory Panel review 4/2023. Medical Director review 4/2023. (tt)

5/1/24 References added. Policy guidelines updated. No change to policy statement. Specialty Matched Consultant Advisory Panel review 4/2024. Medical Director review 4/2024. (tt)