Diagnosis and Treatment of Sacroiliac Joint Pain

POLICY NUMBER

L.6.01.413

DESCRIPTION

Sacroiliac Joint Pain

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 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 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.

A number of percutaneous or minimally invasive fixation/fusion devices have been cleared for marketing by the FDA through the 510(k) process. They include the iFuse® Implant System (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 (STANT Medical), SambaScrew® (Orthofix), and the SI-LOK Sacroiliac Joint Fixation System (Globus Medical).

POLICY

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."

Minimally invasive fixation/fusion of the sacroiliac joint using a titanium triangular implant may be considered medically necessary when ALL of the following criteria have been met:

• Pain is at least 5 on a 0 to 10 rating scale that impacts quality of life or limits activities of daily living; AND

• There is an absence of generalized pain behavior (eg, somatoform disorder) or generalized pain disorders (eg, fibromyalgia); AND

• Patients have undergone and failed a minimum 6 months of intensive nonoperative treatment that must include medication optimization, activity modification, bracing, and active therapeutic exercise targeted at the lumbar spine, pelvis, sacroiliac joint, and hip, including a home exercise program; AND

• Pain is caudal to the lumbar spine (L5 vertebra), localized over the posterior sacroiliac joint, and consistent with sacroiliac joint pain; AND

• A thorough physical examination demonstrates localized tenderness with palpation over the sacral sulcus (Fortin’s point) in the absence of tenderness of similar severity elsewhere; AND

• There is a positive response to a cluster of 3 provocative tests (eg, thigh thrust test, compression test, Gaenslen sign, distraction test, Patrick test, posterior provocation test); AND

• Diagnostic imaging studies include ALL of the following:

  • Imaging (plain radiographs and computed tomography or magnetic resonance imaging) of the sacroiliac joint excludes the presence of destructive lesions (eg, tumor, infection) or inflammatory arthropathy of the sacroiliac joint; AND

  • Imaging of the pelvis (anteroposterior plain radiograph) rules out concomitant hip pathology; AND

  • Imaging of the lumbar spine (computed tomography or magnetic resonance imaging) is performed to rule out neural compression or other degenerative condition that can be causing low back or buttock pain; AND

  • Imaging of the sacroiliac joint indicates evidence of injury and/or degeneration; AND

• There is at least a 75% reduction in pain for the expected duration of the anesthetic used following an image-guided, contrast-enhanced intra-articular sacroiliac joint injection on 2 separate occasions; AND

• A trial of a therapeutic sacroiliac joint injection (ie, corticosteroid injection) has been performed on at least once.

Fixation/fusion of the sacroiliac joint for the treatment of back pain presumed to originate from the sacroiliac joint is considered investigational under all other conditions and with any other devices not listed above.

Radiofrequency denervation of the sacroiliac joint is considered investigational.

POLICY EXCEPTIONS

Federal Employee Program (FEP) may dictate that all FDA-approved devices, drugs or biologics may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity.

POLICY GUIDELINES

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

Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:

A.  consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and

B.  appropriate with regard to standards of good medical practice; and

C.  not solely for the convenience of the Member, his or her Provider; and

D.  the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.

For the definition of medical necessity, “standards of good 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. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.

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.

POLICY HISTORY

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 Reference 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.

01/31/2018: Policy description updated regarding devices. Added policy statement that minimally invasive fusion/stabilization of the sacroiliac joint using a titanium triangular implant may be considered medically necessary when certain criteria are met. Investigational statement revised to state that fusion/stabilization of the sacroiliac joint for the treatment of back pain presumed to originate from the sacroiliac joint is considered investigational under all conditions and with any other devices not listed above. Code Reference section updated to move CPT code 27279 from investigational to covered. Added ICD-10 procedure codes 0SG734Z and 0SG834Z to the Covered Codes table. Removed deleted CPT code 73542.

11/30/2018: Added policy statement that radiofrequency denervation of the sacroiliac joint is considered investigational.

01/29/2019: Policy description updated regarding devices. Policy statements updated to change "fusion/stabilization" to "fixation/fusion."

12/19/2019: Code Reference section updated to add new CPT code 64451 effective 01/01/2020. Removed deleted ICD-10 procedure codes 0SG70ZZ and 0SG80ZZ.

05/01/2022: Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity." Code Reference section updated to add CPT code 64625.

12/20/2022: Code Reference section updated to revise the description for CPT code 27280, effective 01/01/2023.

01/18/2023: Policy reviewed. Policy statements unchanged. Policy Exceptions updated regarding FEP members.

10/17/2023: Policy reviewed; no changes.

12/21/2023: Code Reference section updated to add new 2024 CPT code 27278, effective 01/01/2024.

10/16/2024: Policy reviewed; no changes.

12/19/2024: Code Reference section updated to add new HCPCS code C1737 effective 01/01/2025.

01/15/2026: Code Reference section updated to revise the code descriptions for CPT codes 27279 and 27278. Effective 01/01/2026.

SOURCE(S)

1. Blue Cross & Blue Shield Association policy #6.01.23

2. 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.

3. 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.

4. Schwarzer AC, April CN, Bogduk N. The sacroiliac joint in chronic low back pain. Spine 1995; 20: 31-37.

CODE REFERENCE

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)

Investigational Codes 

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