Subject:
Sacroiliac Joint Arthrography
Description:
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IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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Sacroiliac joint (SIJ) arthrography using fluoroscopic guidance with injection of an anesthetic has been explored as a diagnostic test for SIJ 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. Treatment of SIJ pain with corticosteroids, radiofrequency ablation (RFA), stabilization, or minimally invasive SIJ fusion has also been explored.
Background
Similar to other structures in the spine, it is assumed that the sacroiliac joint (SIJ) may be a source of low back pain. In fact, before 1928, the SIJ 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 SIJ received less research attention.
Research into SIJ 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, SIJ 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 SIJ pain may include various movement tests, palpation to detect tenderness, and pain descriptions by the patient. Further confounding study of the SIJ is that multiple structures, (eg, posterior facet joints, lumbar discs) may refer pain to the area surrounding the SIJ.
Because of inconsistent information obtained from history and physical examination, some have proposed the use of image-guided anesthetic injection into the SIJ for the diagnosis of SIJ pain. Treatments being investigated for SIJ pain include prolotherapy (see separate policy on 'Prolotherapy" - Policy #063 in the Treatment Section), corticosteroid injection, radiofrequency ablation, stabilization, and arthrodesis.
Related Policies
- Prolotherapy (Policy #063 in the Treatment Section)
- Sacroiliac Joint Injections (Policy #108 in the Treatment Section)
- Percutaneous Vertebroplasty and Sacroplasty (Policy #029 in the Treatment Section)
- Radiofrequency Joint Ablation/Denervation (Policy #158 in the Treatment Section)
Policy:
(NOTE: For Medicare Advantage, please refer to the Medicare Coverage Section below for coverage guidance.)
Sacroiliac joint arthrography (i.e., a formal arthrography is performed and a formal radiological diagnostic report is issued) is considered investigational in the evaluation of sacroiliac joint pain.
Medicare Coverage:
There is no National Coverage Determination (NCD) or Local Coverage Determination (LCD) for jurisdiction JL for this service. Therefore, Medicare Advantage will follow the Horizon BCBSNJ Medical Policy.
[RATIONALE: No studies were identified that described how the results of sacroiliac joint arthrography might be used in the management of the patient.]
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Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
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Index:
Sacroiliac Joint Arthrography
SI Joint Arthrography
Arthrography, Sacroiliac Joint
References:
1. Elgafy H, Semaan HB, Ebraheim NA, et al. Computed tomography findings in patients with sacroiliac pain. Clin Orthop. 2001 Jan;382:112-118.
2. van der Wurff P, Meyne W, Hagmeijer RH. Clinical tests of the sacroiliac joint. Man Ther. 2000 May:5(2):89-96.
3. Calvillo O, Skaribas I, Turnispeed J. Anatomy and pathophysiology of the sacroiliac joint. Curr Rev Pain. 2000;4(5):356-361.
4. Ojala R, Klemola R, Karppinen J et al. Sacro-iliac joint arthrography in low back pain: feasibility of MRI guidance. Eur J Radiol 2001 Dec;40(3):236-9.
5. Malanga GA, Nadler SF. Nonoperative treatment of low back pain. Mayo Clin Proc. Nov 1999;74(11):1135-48.
6. Wheeler AH. Therapeutic injections for pain management. eMedicine. Last updated: August 4, 2005. Available at: http://www.emedicine.com/neuro/topic514.htm.
7. North American Society. Phase III Clinical Guidelines for Multidisciplinary Spine Care Specialists: Unremitting Low Back Pain. NASS Task Force on Clinical Guidelines. Version 1.0, 2000.
8. Boswell MV, Shah RV, Everett CR et al. Interventional techniques in the management of chronic spinal pain: Evidence-based practice guidelines. Pain Physician. 2005;8:1-47.
9. Institute for Clinical Systems Improvement (ICSI). Health Care Guideline: Adult Low Back Pain. 11th Edition, September 2005.
10. ECRI Institute. Custom Hotline Response: Sacroiliac Joint Injections for Back and Lower Extremity Pain. Updated: 05/21/2008.
11. Boswell MV, Trescot AM, Datta S, et al. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician 2007 Jan;10(1):7-111.
12. Hansen HC, McKenzie-Brown AM, Cohen SP, et al. Sacroiliac joint interventions: a systematic review. Pain Physician 2007 Jan;10(1):165-84.
13. 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 May;12(3):274-80.
14. 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.
15. Manchikanti L, Datta S, Derby R et al. 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, Abdi S, Atluri S et al. An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain Physician 2013; 16(2 Suppl):S49-283.
17. Hansen H, Manchikanti L, Simopoulos TT et al. A systematic evaluation of the therapeutic effectiveness of sacroiliac joint interventions. Pain Physician 2012; 15(3):E247-78.
18. Visser LH, Woudenberg NP, de Bont J et al. Treatment of the sacroiliac joint in patients with leg pain: a randomized-controlled trial. Eur Spine J 2013; 22(10):2310-7.
19. American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Practice guidelines for chronic pain management: An Updated Report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiolog 2010; 112(4):810-33. 2010. Available online at: http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1932775
Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)
CPT*
HCPCS
* CPT only copyright 2019 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
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