BCBS of Kansas Medical Policy Update

Title:   Diagnosis and Treatment of Sacroiliac Joint Pain

 POLICY Current Effective Date:   September 18, 2015

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; AND
6. 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
2.  Repeat injections extending beyond 12 months may be reviewed for continued medical necessity

B. Sacroiliac injection is considered experimental / investigational for all other indications.

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

D. Radiofrequency ablation of the sacroiliac joint is considered experimental / investigational.

E. 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

1. This policy does not address treatment of pain in the sacroiliac joint due to infection, trauma, or neoplasm.
2. Conservative nonsurgical therapy for the duration specified should include the following:
   1. Use of prescription strength analgesics for several weeks at a dose sufficient to induce a therapeutic response
      1. Analgesics should include anti-inflammatory medications with or without adjunctive medications such as nerve membrane stabilizers or muscle relaxants, AND
   2. Participation in at least 6 weeks of physical therapy (including active exercise) or documentation of why the patient could not tolerate physical therapy, AND
   3. Evaluation and appropriate management of associated cognitive, behavioral, or addiction issues, AND
   4. Documentation of patient compliance with the preceding criteria.

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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).