mp-558
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Diagnosis and Treatment of Sacroiliac Joint Pain

Policy Number: MP-558

Latest Review Date: December 2019

Category: Surgery                                                                  

Policy Grade:  A

 

POLICY:

Effective for dates of services on or after May 14, 2017:

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

  • Pain has failed to respond to 3 months of conservative therapy*; 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 for the treatment of sacroiliac joint pain may be considered medically necessary when ALL of the following criteria have been met:

  • Pain has failed to respond to 3 months of conservative therapy*; AND
  • The injection is performed under imaging guidance; AND
  • No more than 3 injections are given in one year.

Arthrography of the sacroiliac joint is considered not medically necessary and investigational.

Radiofrequency denervation of the sacroiliac joint is considered not medically necessary and investigational.

Cryoablation (cryodenervation, cryoneurolysis, cryosurgery, or cryoanesthesia) of the sacroiliac joint is considered not medically necessary and investigational.

 

Effective for dates of service prior to May 14, 2017:

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

  • Pain has failed to respond to 3 months of conservative therapy*; 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 for the treatment of sacroiliac joint pain may be considered medically necessary when ALL of the following criteria have been met:

  • Pain has failed to respond to 3 months of conservative therapy*; AND
  • The injection is performed under imaging guidance; AND
  • No more than 3 injections are given in one year.

Arthrography of the sacroiliac joint is considered not medically necessary and investigational.

Radiofrequency denervation of the sacroiliac joint is considered not medically necessary and investigational.

*Conservative therapy is the use of structured physician-directed modalities which may include: prescription strength analgesics/anti-inflammatory medications if not contraindicated; participation in therapeutic physical medicine modality(ies) and/or manipulations when rendered by an eligible provider (including active exercise).

 

** A successful trial of controlled diagnostic lateral branch blocks consists of two separate positive blocks on different days with local anesthetic only (no steroids or other drugs), or a placebo-controlled series of blocks, under fluoroscopic guidance, that has resulted in a reduction in pain for the duration of the local anesthetic used (e.g., three hours longer with bupivacaine than lidocaine). There is not a consensus on whether a minimum of 50% or 75% reduction in pain would be required to be considered a successful diagnostic block, although evidence supports a criterion standard of 75% to 100% reduction in pain with dual blocks. No therapeutic intra-articular injections (i.e., steroids, saline, and other substances) should be administered for a period of at least four weeks before the diagnostic lateral branch block. The diagnostic blocks should not be conducted under intravenous sedation unless specifically indicated (e.g., the patient is unable to cooperate with the procedure).

DESCRIPTION OF PROCEDURE OR SERVICE:

Sacroiliac joint 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), and stabilization 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, before 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 thwarted by any 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 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. Cryoablation is a minimally invasive procedure that involves the use of extreme cold to destroy abnormal tissue. Treatments being investigated for sacroiliac joint pain include prolotherapy (refer to policy # 235 Prolotherapy), corticosteroid injection, RFA, stabilization, and arthrodesis. For indications and coverage criteria related to sacroiliac arthrodesis and minimally invasive procedures related to the SI joint please refer to policy #555 Sacroiliac Joint Fusion. Also this policy does not address treatment of pain in the sacroiliac joint due to infection, trauma, or neoplasm.

KEY POINTS:

The most recent literature review was performed through August 28, 2019. Following is a summary of key references to date.

Summary of Evidence

For individuals who have suspected SIJ pain who receive a diagnostic sacroiliac block, the evidence includes systematic reviews. The relevant outcomes are test validity, symptoms, functional outcomes, QOL, medication use, and treatment-related morbidity. Current evidence is conflicting on the diagnostic utility of SIJ blocks. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have SIJ pain who receive therapeutic corticosteroid injections, the evidence includes small RCTs and case series. The 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 two small RCTs showed that therapeutic SIJ steroid injections were not as effective as other active treatments. Larger trials, preferably using sham injections, are needed to determine the degree of benefit of corticosteroid injections over placebo. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have SIJ pain who receive RFA, the evidence includes four small RCTs using different radiofrequency applications and case series. The relevant outcomes are symptoms, functional outcomes, QOL, medication use, and treatment-related morbidity. For RFA with a cooled probe, the two small RCTs reported short-term benefits, but these are insufficient to determine the overall effect on health outcomes. The RCT on palisade RFA of the SIJ did not include a sham control. Another sham-controlled randomized trial 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 the effects of the technology on health outcomes.

Practice Guidelines and Position Statements

American Society of Interventional Pain Physicians Interventional Pain Management

American Society of Interventional Pain Physicians Interventional Pain Management guidelines were updated in 2013. The updated guidelines recommend the use of controlled sacroiliac joint blocks with placebo or controlled comparative local anesthetic block when indications are satisfied with suspicion of sacroiliac joint 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. For therapeutic interventions, the only effective modality with fair evidence was cooled radiofrequency neurotomy, when used after the appropriate diagnosis was confirmed by diagnostic sacroiliac joint injections.

American Society of Anesthesiologists et al

In 2010, the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine Practice updated their guidelines for chronic pain management. The guidelines recommend that diagnostic sacroiliac joint injections or lateral branch blocks may be considered for the evaluation of patients with suspected sacroiliac joint pain. Based on opinions of consultants and society members, the guidelines recommend that water-cooled RFA or sacroiliac joint injections may be used for chronic sacroiliac joint pain.

American Pain Society

The 2009 practice guidelines from the American Pain Society (APS) were based on a systematic review that was commissioned by the APS and conducted at the Oregon Evidence-based Practice Center. The APS guideline states that there is insufficient evidence to evaluate validity or utility of diagnostic sacroiliac joint block as a diagnostic procedure for low back pain with or without radiculopathy and that there is insufficient evidence to adequately evaluate benefits of sacroiliac joint steroid injection for non-radicular low back pain.

U.S. Preventive Services Task Force Recommendations

Not Applicable.

KEY WORDS:

Arthrography, Sacroiliac Joint Arthrography, Sacroiliac Joint Radiofrequency Ablation or Denervation, SI joint Injections, Diagnostic Blocks, Cryodenervation, Cryoneurolysis, Cryosurgery, Cryoanesthesia, Cryoablation

APPROVED BY GOVERNING BODIES:

A number of radiofrequency generators and probes have been cleared for marketing through the U.S. Food and Drug Administration’s (FDA) 510(k) process. One device, the SInergy® by Halyard; formerly Kimberly Clark/Baylis, is a water-cooled single-use probe that received FDA clearance in 2005, 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.

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits.  Group specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply.

FEP:  Special benefit consideration may apply.  Refer to member’s benefit plan.  FEP does not consider investigational if FDA approved and will be reviewed for medical necessity.

CURRENT CODING: 

CPT Codes:

27096

Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed

20552

Injection(s); single or multiple trigger points(s), 1 or 2 muscle(s)

27299

Unlisted procedure, pelvis or hip joint

64451

Injection(s), anesthetic agent(s) and/or steroid; nerves innervating the sacroiliac joint, with image guidance (i.e., fluoroscopy or computed tomography) (Effective 01/01/20)

64625

Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (i.e., fluoroscopy or computed tomography) (Effective 01/01/20)

64999

Unlisted procedure, nervous system

 

HCPCS Codes:

G0259

Injection procedure for sacroiliac joint; arthrography

G0260

Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography

 

REFERENCES:

  1. Althoff CE, Bollow M, Feist E, et al. CT-guided corticosteroid injection of the sacroiliac joints: quality assurance and standardized prospective evaluation of long-term effectiveness over six months. Clin Rheumatol. Jun 2015; 34(6):1079-1084.
  2. American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiolog 2010; 112(4):810-833. 2010. https://www.journals.lww.com/anesthesiology/fulltext/2010/04000/practice_guidelines_for_chronic_pain_management_.13.aspx.
  3. Ashman B, Norvell DC, Hermsmeyer JT. Chronic sacroiliac joint pain: fusion versus denervation as treatment options. Evid Based Spine Care J. Dec 2010; 1(3):35-44.
  4. Aydin SM, Gharibo CG, Mehnert M et al. The role of radiofrequency ablation for sacroiliac joint pain: a meta-analysis. PM R 2010; 2(9):842-851.
  5. Birkenmaier C, Veihelmann A, Trouillier H, et al. Percutaneous cryodenervation of lumbar facet joints: a prospective clinical trial. Int Orthop. 2007; 31(4):525-530.
  6. Boswell MV, Trescot AM, Datta S et al. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician 2007; 10(1):7-111.
  7. Chen CH, Weng PW, Wu LC et al. Radiofrequency neurotomy in chronic lumbar and sacroiliac joint pain: A meta-analysis. Medicine (Baltimore), 2019 Jul 3;98(26).
  8. Chou R, Atlas SJ, Stanos SP et al. Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine (Phila Pa 1976) 2009; 34(10):1078-1093.
  9. Chou R, Loeser JD, Owens DK et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine (Phila Pa 1976) 2009; 34(10):1066-1077.
  10. Cohen SP, Hurley RW, Buckenmaier CC, 3rd et al. Randomized placebo-controlled study evaluating lateral branch radiofrequency denervation for sacroiliac joint pain. Anesthesiology 2008; 109(2):279-288.
  11. Dreyfuss P, Michaelsen M, Pauza K et al. The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine (Phila Pa 1976) 1996; 21(22):2594-2602.
  12. Hansen H, Manchikanti L, Simopoulos TT et al. A systematic evaluation of the therapeutic effectiveness of sacroiliac joint interventions. Pain Physician 2012; 15(3):E247-278.
  13. Hansen HC, McKenzie-Brown AM, Cohen SP et al. Sacroiliac joint interventions: a systematic review. Pain Physician 2007; 10(1):165-184.
  14. Kennedy DJ, Engel A, Kreiner DS, et al. Fluoroscopically guided diagnostic and therapeutic intra-articular sacroiliac joint injections: A systematic review. Pain Med. Aug 2015; 16(8):1500-1518.
  15. Kim WM, Lee HG, Jeong CW et al. A randomized controlled trial of intra-articular prolotherapy versus steroid injection for sacroiliac joint pain. J Altern Complement Med 2010; 16(12):1285-1290.
  16. Maigne JY, Aivaliklis A, Pfefer F. Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain. Spine (Phila Pa 1976) 1996; 21(16):1889-1892.
  17. 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.
  18. 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 2013; 16(2 Suppl):S49-283.
  19. 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; 13(3):E141-174.
  20. 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):E215-264.
  21. Mehta V, Poply K, Husband M et al. The Effects of Radiofrequency Neurotomy Using a Strip-Lesioning Device on Patients with Sacroiliac Joint Pain: Results from a Single-Center, Randomized, Sham-Controlled Trial. Pain Physician, 2018 Dec 5;21(6). 
  22. Murakami E, Tanaka Y, Aizawa T et al. Effect of periarticular and intraarticular lidocaine injections for sacroiliac joint pain: prospective comparative study. J Orthop Sci 2007; 12(3):274-280.
  23. Patel N. Twelve-month follow-up of a randomized trial assessing cooled radiofrequency denervation as a treatment for sacroiliac region pain. Pain Pract. Feb 2016; 16(2):154-167.
  24. Patel N, Gross A, Brown L et al. A randomized, placebo-controlled study to assess the efficacy of lateral branch neurotomy for chronic sacroiliac joint pain. Pain Med 2012; 13(3):383-389.
  25. 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.
  26. Schwarzer AC, Aprill CN, Bogduk N. The sacroiliac joint in chronic low back pain. Spine (Phila Pa 1976) 1995; 20(1):31-37.
  27. Simopoulos TT, Manchikanti L, Gupta S et al. Systematic Review of the Diagnostic Accuracy and Therapeutic Effectiveness of Sacroiliac Joint Interventions. Pain Physician, 2015 Oct 3;18(5).
  28.  Spiker WR, Lawrence BD, Raich AL, et al. Surgical versus injection treatment for injection-confirmed chronic sacroiliac joint pain. Evid Based Spine Care J. Nov 2012; 3(4):41-53.
  29. van Tilburg CW, Schuurmans FA, Stronks DL, et al. Randomized sham-controlled double-blind multicenter clinical trial to ascertain the effect of percutaneous radiofrequency treatment of sacroiliac joint pain: three-month results. Clin J Pain. Nov 2016; 32(11):921-926.
  30. Visser LH, Woudenberg NP, de Bont J et al. Treatment of the sacroiliac joint in patients with leg pain: a randomized-controlled trial. Eur Spine J 2013; 22(10):2310-2317.
  31. Weksler N, Velan GJ, Semionov M et al. The role of sacroiliac joint dysfunction in the genesis of low back pain: the obvious is not always right. Arch Orthop Trauma Surg 2007; 127(10):885-888.
  32. Zheng Y, Gu M, Shi D, et al. Tomography-guided palisade sacroiliac joint radiofrequency neurotomy versus celecoxib for ankylosing spondylitis: A open-label, randomized, and controlled trial. Rheumatol Int. Sep 2014; 34(9):1195-1202.

POLICY HISTORY:

Medical Policy Panel, May 2014

Medical Policy Group, July 2014 (3): New Policy removed section from policy 303 related to SI joint injections as well as section from 141 related to SI joint denervation

Medical Policy Administration Committee, August 2014

Available for comment September 8 through October 22, 2014

Medical Policy Group, September 2014 (3): added word “modality(ies)” to description of physical therapy in conservative therapy definition per Medical Director

Medical Policy Panel, April 2015

Medical Policy Group, May 2015 (2): 2015 Updates to Description, Key Points, Current Coding- added CPT code 20552, and References; no change to Policy statement.

Medical Policy Group, May 2015 (2): HCPCS codes G0259 and G0260 added to policy.

Medical Policy Panel, November 2015

Medical Policy Group, November 2015 (2): Updates to Key Points, Approved by Governing Bodies, and References; no change in policy statement.

Medical Policy Panel, August 2016

Medical Policy Group, August 2016 (7): Updates to Key Points and References. Policy Statement intent remains unchanged. Clarification to wording – removed “for the purpose” and added “anesthetic for.”

Medical Policy Panel, October 2016

Medical Policy Group, October 2016 (7): Updates to Key Points. No change in Policy Statement.

Medical Policy Group, March 2017 (7): Updates to Description, Key Points, Key Words, Current Coding- added CPT code 64999, and References. Also, added cryoablation as investigational to Policy Statement.

Available for comment March 30 through May 13, 2017

Medical Policy Group, April 2017 (7): Clarification to “conservative therapy” definition.

Medical Policy Panel, December 2017

Medical Policy Group, December 2017 (7): 2017 Updates to Key Points and References. No change in Policy Statement.

Medical Policy Panel, November 2019

Medical Policy Group, December 2019 (7): 2019 Updates to Key Points and References. No change in Policy Statement.

Medical Policy Group, December 2019: 2020 Annual Coding Update. Added CPT codes 64451 and 64625 to the Current coding section. No change in Policy Statement.

 

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

  1. The technology must have final approval from the appropriate government regulatory bodies;
  2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;
  3. The technology must improve the net health outcome;
  4. The technology must be as beneficial as any established alternatives;
  5. The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

  1. In accordance with generally accepted standards of medical practice; and
  2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and
  3. Not primarily for the convenience of the patient, physician or other health care provider; and
  4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.