July 1, 2011

Effective Date: July 27, 2011

State and Federal mandates and health plan member contract language, including specific provisions/exclusions, take precedence over Medical Policy and must be considered first in determining eligibility for coverage. To verify a member's benefits, contact Blue Cross and Blue Shield of Kansas Customer Service.

The BCBSKS Medical Policies contained herein are for informational purposes and apply only to members who have health insurance through BCBSKS or who are covered by a self-insured group plan administered by BCBSKS. Medical Policy for FEP members is subject to FEP medical policy which may differ from BCBSKS Medical Policy.

The medical policies do not constitute medical advice or medical care. Treating health care providers are independent contractors and are neither employees nor agents of Blue Cross and Blue Shield of Kansas and are solely responsible for diagnosis, treatment and medical advice.

If your patient is covered under a different Blue Cross and Blue Shield plan, please refer to the Medical Policies of that plan.

DESCRIPTION

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.

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 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.

POLICY

A. Injection into the sacroiliac joint for diagnostic or therapeutic purposes may be considered medically necessary when all of the following conditions are met:

1. Pain originates from the sacroiliac joint; and
2. Duration of pain of at least 3 months; and
3. Average pain level of = 6 on a scale of 1 to 10; and
4. Failure to respond to more conservative management including physical therapy and non-steroidal anti-inflammatory agents; and
5. Lack of obvious evidence for disc related or facet joint pain

Repeat Injections:

1. Repeat injections are to be no more frequent than every 2 months
2. Repeat injections extending beyond 12 months may be reviewed for continued medical necessity

B. Sacroiliac injections are considered experimental / investigational for all other indications.

C. Arthrography of the sacroiliac joint is considered experimental / investigational.

RATIONALE

The use of diagnostic blocks to evaluate sacroiliac joint pain builds on the experience of use of diagnostic block in other joints to evaluate pain. Blinded studies with placebo controls (although difficult to conduct when dealing with invasive procedures) are ideally required for scientific validation of sacroiliac joint blocks, particularly when dealing with pain relief, well-known to respond to placebo controls. In the typical evaluation of a diagnostic test, the results of sacroiliac diagnostic block would then be compared to a gold standard. However, there is no current gold standard for sacroiliac joint injection. In fact, some authors have positioned sacroiliac joint injection as the gold standard, against which other diagnostic tests and physical exam may be measured. (1) Finally, one would like to know how the results of a diagnostic test will be used in the management of the patient, and whether the subsequent treatment plan results in beneficial health outcomes.

There is minimal literature regarding sacroiliac joint blocks. Schwarzer and colleagues reported on a case series of 43 patients with unexplained low back pain below L5-S1. (2) These 43 patients were chosen opportunistically from a larger group of patients referred for discography or zygapophyseal joint blocks. Thus all patients underwent multiple procedures. A total of 13 of the 43 patients (30%) reported relief of their pain with sacroiliac joint blocks. There were no blinded controls, although the authors felt that the use of pain blocks at the zygapophyseal joints functioned as internal controls. The authors concluded that these results refuted the null hypothesis that sacroiliac joint pain does not exist and that sacroiliac joint blocks should be further investigated as a criterion standard for the diagnosis of sacroiliac joint pain. Maigne and colleagues reported on a series of 54 patients with low back pain who received double sacroiliac joint block. (3) The first block used lidocaine, a short-acting anesthetic. If the patient reported pain relief, a second, confirmatory block was performed 1 week later using a long-acting anesthetic. If similar relief was obtained with the second block, it was concluded that the sacroiliac joint was the source of the pain. A total of 18% of patients met these criteria. Similar to the Schwarzer et al. study, this study was designed primarily to demonstrate that sacroiliac pain exists and to assess its prevalence.

At the time this policy was created, there were no studies that described how the results of sacroiliac joint arthrography might be used in the management of the patient.

2006-2008 Updates

Searches of the literature were performed on the MEDLINE database through July 2008. One publication focused on the technique of sacroiliac joint injection. (4) Several other retrospective case series have been reported. (5-7) One case series reported results of diagnostic/therapeutic blocks in patients who were referred for low back pain and disc herniation without claudication or neurologic abnormalities. (7) Fifty patients who had at least 3 positive pain provocation tests for sacroiliac joint dysfunction received sacroiliac injection of bupivacaine and betamethasone. Pain, assessed by visual analogue scores (VAS), improved from 7.8 to 1.3 at 30 minutes after the injection. At a 12-week follow-up, 46 patients (92%) reported VAS scores of 3 or less. Four patients required hospitalization for an unanticipated motor block. A placebo-controlled randomized trial examined the effect of lateral branch radiofrequency denervation in 28 patients with injection-diagnosed sacroiliac joint pain. (8) Two of 14 patients (14%) in the placebo-control group reported pain relief at 1-month follow-up. None reported benefit at 3-month follow-up. Of the 14 patients treated with radiofrequency denervation, 11 (79%) reported pain relief at 1 month, 9 (64%) at 3 months, and 8 (57%) at 6 months. Questions remain about intra-articular versus peri-articular sources of sacroiliac pain. One prospective comparison found that periarticular lidocaine injections (25 of 25 patients) were more effective than intra-articular injection (9 of 25 patients). (9) Another study found that sacroiliac joint injections were ineffective in the management of patients with inflammatory spondyloarthropathy. (10)

2009-2010 Updates

An updated literature search using the MEDLINE database in October 2009 identified 2 new guidelines based on systematic reviews. (11-14) The American Society of Interventional Pain Physicians (ASIPP) derived their updated guideline on a systematic review of sacroiliac injections by Manchikanti et al. and Rupert et al. (11,12) This systematic review included 13 studies utilizing fluoroscopically guided controlled diagnostic blocks (i.e., placebo-controlled or comparative local anesthetic) in patients with chronic low back and/or lower extremity pain for greater than 3 months in duration. Five studies, considered level II-2 evidence (well-designed cohort or case-control studies), were reviewed on the topic of diagnosis of sacroiliac joint pain using a double-block paradigm (comparative controlled local anesthetic blocks). The false-positive rate for use of a single, uncontrolled, sacroiliac joint injection was 20% to 54%. With a double-block paradigm, the prevalence of sacroiliac joint pain was estimated to range between 10% and 38% in patients with a high likelihood of sacroiliac joint pain. Interpretation of these results is limited by the lack of a “gold” standard for reference comparison. ASIPP concluded that sacroiliac joint blocks appear to be the evaluation of choice to provide appropriate diagnosis, due to the inability to make the diagnosis of sacroiliac joint-mediated pain with noninvasive tests. (11) For therapeutic intra-articular sacroiliac joint interventions, 4 randomized trials were excluded from review due to a lack of a valid diagnosis prior to therapeutic interventions. None of the 14 observational reports met the inclusion criteria, due to lack of controlled diagnostic blocks to establish diagnosis, evaluating only patients with spondyloarthropathy, or not following patients for 6 months. Limitations were noted as a paucity of literature evaluating the role of both diagnostic and therapeutic interventions and widespread methodologic flaws.

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. (13,14) The systematic review concluded that no reliable evidence existed to evaluate validity or utility of diagnostic sacroiliac joint block as a diagnostic procedure for low back pain with or without radiculopathy, with a resulting guideline recommendation of insufficient evidence. Data on sacroiliac joint steroid injection were limited to 1 small controlled trial, resulting in a recommendation of insufficient evidence for therapeutic injection of this joint.

2011 Update

A search of the literature using the MEDLINE database was conducted in January 2011. Manchikanti and colleagues published critical reviews of the APS guidelines (13,14, referred to earlier) for interventional techniques, including sacroiliac injections. (15,16) Evidence for diagnostic sacroiliac injections was considered to be fair to poor, and no additional literature was identified since the 2009 systematic review by Rupert and colleagues (12) that found limited evidence for therapeutic sacroiliac injections.

Clinical Input Received through Physician Specialty Societies and Academic Medical Centers

While the various physician specialty societies and academic medical centers may collaborate with and make recommendations during this process through the provision of appropriate reviewers, input received does not represent an endorsement or position statement by the physician specialty societies or academic medical centers, unless otherwise noted.

In response to requests, input was received from 4 physician specialty societies (6 responses) and 3 academic medical centers (5 responses) while this policy was under review in 2010. Clinical input was mixed. There was general agreement that the evidence for sacroiliac joint injections is limited, although a majority of reviewers considered sacroiliac injections to be the best available approach for diagnosis and treatment in defined situations.

Summary

There is limited prospective or controlled evidence for sacroiliac joint arthrography or injection therapy. It should be noted that, in general, the literature regarding injection therapy on other joints in the back is of poor quality. Overall, sacroiliac arthrography and injection have not been adequately evaluated. Evidence is insufficient to permit conclusions regarding the effect of this procedure on health outcomes.

Technology Assessments, Guidelines, and Position Statements

In 2007, ASIPP published Systematic Review and Practice Guidelines, including sacroiliac joint interventions. (17,18) Evidence was determined to be moderate (level III, non-randomized comparative trials) for the accuracy of sacroiliac joint diagnostic injections for the diagnosis of sacroiliac joint pain. The authors report that “even though short-term relief from sacroiliac joint injection is considered as a gold standard for the diagnosis of sacroiliac joint pain, there was no blinded comparison of the test or reference standard in evaluation of these investigations.” The evidence for intra-articular sacroiliac joint injections for short- and long-term relief was found to be limited (level IV, case series).

The ASIPP Interventional Pain Management guidelines were updated in 2009. The guidelines for diagnostic and therapeutic sacroiliac joint injections were based on the systematic review by Manchikanti et al. and Rupert et al. described earlier.(11,12) Evidence for sacroiliac joint injections was considered to be level II-2 (evidence obtained from at least 1 properly designed small diagnostic accuracy study). The guidelines indicate that sacroiliac joint blocks appear to be the evaluation of choice to provide appropriate diagnosis, due to the inability to make the diagnosis of sacroiliac joint-mediated pain with non-invasive tests. Evidence was determined to be unavailable to establish efficacy of intra-articular sacroiliac joint injections for therapeutic purposes.

Common indications for sacroiliac joint injections were listed as follows:

• Somatic or nonradicular low back and lower extremity pain below the level of L5 vertebra.
• Duration of pain of at least 3 months.
• Average pain levels of > 6 on a scale of 0 to 10.
• Intermittent or continuous pain causing functional disability.
• Failure to respond to more conservative management, including physical therapy modalities with exercises, chiropractic management, and non-steroidal anti-inflammatory agents.
• Lack of obvious evidence for disc-related or facet joint pain.
• No contraindications with understanding of consent, nature of the procedure, needle placement, or sedation.
• No history of allergy to contrast administration, local anesthetics, steroids, Sarapin, or other drugs potentially utilized.
• Contraindications or inability to undergo physical therapy, chiropractic management, or inability to tolerate non-steroidal anti-inflammatory drugs.
• For therapeutic sacroiliac joint interventions with intra-articular injections or radiofrequency neurotomy, the joint should have been positive utilizing controlled diagnostic blocks.

Recommended frequency of interventions was also described.

2009 practice guidelines from the APS were based on a systematic review that was commissioned by the APS and conducted at the Oregon Evidence-Based Practice Center. (13,14) 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 nonradicular low back pain.

CODING

• In the year 2000, two CPT codes were introduced to explicitly identify sacroiliac joint arthrography: 27096 and 73542. CPT code 77003 may also be used for fluoroscopic guidance of the injection procedure when no formal arthrography is performed.

REVISIONS

07-27-2011 Policy added to the bcbsks.com web site.

REFERENCES

1. Dreyfuss P, Michaelsen M, Pauza K et al. The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine 1996; 21(22):2594-602.
2. Schwarzer AC, Aprill CN, Bogduk N. The sacroiliac joint in chronic low back pain. Spine 1995; 20(1):31-7.
3. 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 1996; 21(16):1889-92.
4. Dussault RG, Kaplan PA, Anderson MW. Fluoroscopy-guided sacroiliac joint injections. Radiology 2000; 214(1):273-7.
5. Elgafy H, Semaan HB, Ebraheim NA et al. Computed tomography findings in patients with sacroiliac pain. Clin Orthop Relat Res 2001; 382:112-8.
6. Slipman CW, Lipetz JS, Plastaras CT et al. Fluoroscopically guided therapeutic sacroiliac joint injections for sacroiliac joint syndrome. Am J Phys Med Rehabil 2001; 80(6):425-32.
7. 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):885-8.
8. 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):279-88.
9. 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):274-80.
10. Hanly JG, Mitchell M, MacMillan L et al. Efficacy of sacroiliac corticosteroid injections in patients with inflammatory spondyloarthropathy: results of a 6 month controlled study. J Rheumatol 2000; 27(3):719-22.
11. 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.
12. 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.
13. Chou R, Loeser JD, Owens DK et al; American Pain Society Low Back Pain Guideline Panel. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine 2009; 34(10):1066-77.
14. 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 2009; 34(10):1078-93.
15. Manchikanti L, Datta S, Derby R et al.; American Pain Society. A critical review of the American Pain Society clinical practice guidelines for interventional techniques: part 1. Diagnostic interventions. Pain Physician 2010; 13(3):E141-74.
16. 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.
17. 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.
18. Hansen HC, McKenzie-Brown AM, Cohen SP et al. Sacroiliac joint interventions: a systematic review. Pain Physician 2007; 10(1):165-84.

abinsights readers are invited to submit comments, questions, tips, and suggestions for articles on any subject related to billing, collections, coding, reimbursement, and compliance. Send to: Anesthesia Billing, Inc., P O Box 388, Newton, KS 67114-0388.

Our purpose is to help you meet inevitable challenges. We hope to deliver practical knowledge and solutions drawn from top resources and business publications in every issue, knowledge you can use today.

Reasonable attempts have been made to be accurate. However, medical billing, collections, coding and compliance are part science, part art, and even experts sometimes differ. Neither Anesthesia Billing, Inc., the editors, publisher, contributors, or consultants warrant or guarantee the information contained will be applicable or appropriate in all situations. For information specific to your practice, consult a qualified professional.

The information included in this publication is provided, among other things, to alert you to legal developments and should not be considered legal advice. Specific questions about how this information affects your particular situation should be addressed to your attorney.

Editor: Philip Blann (pblann@anesthesiabilling.com).