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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 was thought to be the most common cause of sciatica. In 1928, the role of 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 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.
Sacroiliac joint arthrography has been explored as a diagnostic test for sacroiliac joint pain. Using fluoroscopic guidance, the joint cavity can be entered. Once the position is confirmed with the injection of contrast medium, a local anesthetic can be injected. Duplication of the patient's pain pattern with the injection of contrast medium suggests a sacroiliac etiology, as does relief of pain with injection of local anesthetic. Treatment of sacroiliac joint pain with corticosteroids, radiofrequency ablation, stabilization, or minimally invasive arthrodesis has also been explored.
Several percutaneous or minimally invasive fixation/fusion devices have received marketing clearance by the FDA. These include the SI-FIX Sacroiliac Joint Fusion System (Medtronic), the IFUSE Implant System (SI Bone), the SImmetry Sacroiliac Joint Fusion System (Zyga Technologies) and the SI-LOK (Globus Medical).
Sacroiliac joint arthrography under fluoroscopy with injection for diagnostic purposes (and potential pain relief) with or without the anticipation of lumbar fusion is considered medically necessary. Up to TWO injections per calendar year are allowed.
If a provider injects medication without radiographic control, it is not certain if in reality the injection is made into the joint or around it. In such a case, the service is considered to be a "trigger point injection".
Fusion/stabilization of the sacroiliac joint for the treatment of back pain presumed to originate from the SI joint is considered investigational, including but not limited to percutaneous and minimally invasive techniques.
Federal Employee Program (FEP) Members:
Sacroiliac joint arthrography is considered investigational.
Radiofrequency denervation of the saroiliac joint is considered not medically necessary.
Effective 10/15/2014, injection for the purpose of diagnosing sacroiliac joint pain may be considered medically necessary when the following criteria have been met:
Effective 10/15/2014, injection of corticosteroid may be considered medically necessary for the treatment of sacroiliac joint pain when the following criteria have been met:
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
5/2000: Approved by Medical Policy Advisory Committee (MPAC); Sacroiliac joint arthrography with or without injection is considered investigational
11/2000: Revised by MPAC; “Sacroiliac joint arthrography with or without injection is considered investigational.” changed to “Sacroiliac joint arthrography with injection for diagnosis in anticipation of lumbar fusion is medically necessary.” “Sacroiliac joint arthrography injection for therapeutic reasons is considered investigation.” added Policy section, “If a provider injects medication without radiographic control, it is not certain if in reality the injection is made into the joint or around it. In such case, the service is considered to be a trigger point injection.” added Policy section, “Blue Cross and Blue Shield Association policy considers sacroiliac joint arthrography with or without injection investigational. Therefore, this is considered investigational for all FEP subscribers. (See FEP policy)” added Policy Exceptions, Sources updated, “All codes billed for this investigational test are not covered” deleted Code Reference section, “This is not intended to be a comprehensive list of codes. Some codes may be variable and coverage will be based on the clinical indication for the service.” added Code Reference section, covered codes table added, CPT codes 27096, 73542 added covered codes, Managed Care Requirements deleted.
2/8/2002: Investigational definition added
4/22/2002: Type of Service and Place of Service deleted
5/6/2002: Code Reference section updated
5/16/2002: Reviewed by MPAC, no changes
5/30/2002: ICD-9 procedure code 99.23 deleted, ICD-9 procedure code 88.32 added
3/7/2003: Code Reference section updated, HCPCS G0259, G0260 added
7/15/2004: Reviewed by MPAC, sacroiliac joint arthrography with injection for diagnostic purposes (and potential pain relief) with or without the anticipation of lumbar fusion considered medically necessary. Additional injections for pain relief considered NOT medically necessary. This change is effective November 1, 2004.
8/11/2004: Code Reference section reviewed, no changes
10/1/2004: Code Reference section reviewed, no changes
12/13/2004: Clarification under "Policy" to add "a single" as follows: Sacroiliac joint arthrography with a single injection for diagnostic purposes (and potential pain relief) with or without the anticipation of lumbar fusion is considered medically necessary.
1/5/2005: Sacroiliac joint arthrography injection for therapeutic reasons is considered investigational. (added 11/2000) deleted Policy section
3/31/2005: Reviewed by MPAC, "Sacroiliac joint arthrography with a single injection for diagnostic purposes (and potential pain relief) with or without the anticipation of lumbar fusion is considered medically necessary." changed to "Sacroiliac joint arthrography under fluoroscopy with injection for diagnostic purposes (and potential pain relief) with or without the anticipation of lumbar fusion is considered medically necessary." "Additional injections for pain relief are considered NOT medically necessary." deleted Policy section, "Up to TWO injections per calendar year are allowed." added Policy section, this policy change is effective June 1, 2005.
5/6/2005: Code Reference section reviewed, CPT code 27096 note added “Code 27096 is a unilateral procedure. To report bilateral procedure, use modifier -50.” CPT code 76005 added
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
8/18/2008: Policy reviewed, no changes.
6/04/2010: Policy description and statement unchanged. Code Reference section revised to remove CPT Code 76005, which was deleted 12/31/2006.
04/20/2011: Policy reviewed; no changes.
03/27/2012: Policy reviewed; no changes.
05/17/2013: Policy title changed from "Sacroiliac Joint Arthrography" to "Diagnosis and Treatment of Sacroiliac Joint Pain." Policy description updated. Added the following investigational policy statement: Fusion/stabilization of the sacroiliac joint for the treatment of back pain presumed to originate from the SI joint is considered investigational, including but not limited to percutaneous and minimally invasive techniques. Added CPT code 27280 to the Code Reference section as non-covered. Updated the descriptions of CPT code 27096 and 77003.
07/14/2014: Policy reviewed; no changes.
12/24/2014: Policy Exceptions section updated for FEP Members to indicate when injection into the sacroiliac joint for diagnostic or therapeutic purposes may be considered medically necessary effective 10/15/2014.
12/31/2014: Added the following new 2015 CPT code to the Code Reference section: 27279. Revised the description of the following CPT code: 27280. Effective 01/01/2015.
05/27/2015: Removed ICD-9 procedure code 88.32 from the Code Referrence section.
07/13/2015: Code Reference section updated for ICD-10.
01/08/2016: Investigative definition updated in policy guidelines section. Code Reference section updated to add the following ICD-10 procedure codes to the Investigational Codes table: 0SG704Z, 0SG707Z, 0SG70JZ, 0SG70KZ, 0SG70ZZ, 0SG804Z, 0SG807Z, 0SG80JZ, 0SG80KZ, and 0SG80ZZ.
06/08/2016: Policy number L.6.01.413 added.
12/30/2016: Code Reference section updated to revise code description for CPT code 77003.
Dreyfuss P, Michaelsen M, Pauza K, et al. The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine 1996; 21: 2594-2602.
Maigne J, 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 1996; 21: 1889-92.
Schwarzer AC, April CN, Bogduk N. The sacroiliac joint in chronic low back pain. Spine 1995; 20: 31-37.
Blue Cross & Blue Shield Association policy #6.01.23
This may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
Covered Codes (See exception for FEP above)
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