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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).

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.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

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.

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

The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document. 

Covered Codes (See exception for FEP above)

 
This is not an all-inclusive list of non-covered procedure codes.

The code(s) listed below and ANY code not listed in the previous section are considered non-covered for this procedure.

Non-Covered Codes 

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