BCBS of Kansas Medical Policy Update

Title:   Diagnosis and Treatment of Sacroiliac Joint Pain

POLICY Current Effective Date:  April 12, 2017

• 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. Average pain level of ≥ 6 on a scale of 1 to 10 (see Policy Guidelines); AND
3. Failure to respond to nonsurgical conservative management, which should include therapies such as nonsteroidal anti-inflammatory medications, acetaminophen, manipulation, physical therapy, and/or a home exercise program; AND
4. The injections are performed under radiographic guidance with documentation of contrast material throughout the sacroiliac joint.

Note: Ultrasound guidance is not considered adequate or accurate for sacroiliac joint injections

Repeat Injections:

1. If patient has achieved substantial relief with previous injection, repeat injections are to be no more frequent than every 2 months with no more than 3 injections given in one year
2. Repeat injections extending beyond 12 months may be reviewed for continued medical necessity

• Sacroiliac injection is considered experimental / investigational for all other indications.
• Arthrography of the sacroiliac joint is considered experimental / investigational.
• Radiofrequency ablation of the sacroiliac joint is considered experimental / investigational.
• Fusion / stabilization of the sacroiliac joint for the treatment of back pain presumed to originate from the SI joint is considered experimental / investigational, including, but not limited to, percutaneous and minimally invasive techniques.

Policy Guidelines

• This policy does not address treatment of pain in the sacroiliac joint due to infection, trauma, or neoplasm.
• Conservative nonsurgical therapy should include the following:
  • a) Use of prescription strength analgesics at a dose sufficient to induce a therapeutic response
    • Analgesics should include anti-inflammatory medications with or without adjunctive medications such as nerve membrane stabilizers or muscle relaxants, OR
  • b) Participation in physical therapy (including active exercise) or a home exercise program or documentation of why the patient could not tolerate physical therapy or a home exercise program, OR
  • c) Evaluation and appropriate management of associated cognitive, behavioral, or addiction issues, OR
  • d) Documentation of patient compliance with the preceding criteria.
• Pain may be defined as moderate (interferes significantly with ADLs) or severe (disabling; unable to perform ADLs).

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