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Horizon BCBSNJ
Uniform Medical Policy ManualSection:Treatment
Policy Number:108
Effective Date: 09/11/2020
Original Policy Date:05/12/2009
Last Review Date:09/11/2020
Date Published to Web: 08/02/2016
Subject:
Sacroiliac Joint Injections

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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CMM-203: Sacroiliac Joint Injections

CMM-203.1: Definitions
CMM-203.2: General Guidelines
CMM-203.3: Indications
CMM-203.4: Non-Indications
CMM-203.5: Procedure Codes
CMM-203.6: References

CMM-203.1 Definitions

The presence of pain over the sacroiliac joint in the absence of radicular findings in and of itself does not substantiate the diagnosis of sacroiliac joint pain. There must also be clinical evidence as described below.

Intra-articular sacroiliac joint injection refers to the injection of contrast (absent allergy to contrast), followed by the introduction of a corticosteroid and/or a local anesthetic into the sacroiliac joint under fluoroscopic guidance.

Peri-articular injection refers to the introduction of a corticosteroid and/or a local anesthetic to one or more sections of the posterior ligamentous structures of the sacroiliac joint.

Sacral lateral nerve block refers to an injection of corticosteroid and/or local anesthetic adjacent to the sacral lateral nerve resulting in the temporary interruption of conduction of impulses for analgesia. Sacral lateral nerve blocks attempt to block pain signals and theoretically provide relief from pain. The duration of the block depends on the dose, concentration and type of pharmacological agent injected.

Sacroiliac joint pain is defined as pain originating from the sacroiliac joint and/or its supporting ligamentous structures as a result of injury, disease or surgery.

Policy:
(NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)
CMM-203.2 General Guidelines

The determination of medical necessity for the performance of sacroiliac joint injections is always made on a case-by-case basis.

Please note: this policy only applies to injections of anesthetic, corticosteroid, and/or contrast agent and does not apply to injections of biologics (e.g., platelet rich plasma, stem cells, amniotic fluid, etc.) and any other injectates.

Intra-articular sacroiliac joint injections should be performed using fluoroscopy with injection of contrast (absent allergy to contrast) for guidance, as it is considered the standard of care.

Peri-articular sacroiliac joint injections may be performed with or without the use of fluoroscopic guidance.

When sacroiliac joint injections are performed (anesthetic only) for the purpose of diagnosing sacroiliac joint pain, a positive diagnostic response is defined as ≥75% pain relief for the duration of the local anesthetic.

Sacroiliac injections performed for the purpose of treating sacroiliac pain are termed therapeutic sacroiliac injections. When medical necessity criteria is met, a total of four therapeutic sacroiliac injections for the treatment of sacroiliac pain may be performed per joint during a 12 month period of time, with a minimum of two months duration between each injection, for the recurrence of pain.

The performance of interventional pain procedures such as a sacroiliac joint injection does not require the need for supplemental anesthesia in addition to local anesthesia.

CMM-203.3 Indications

The performance of a diagnostic sacroiliac joint injection for localized, sacroiliac joint pain resulting from disease, injury or surgery is considered medically necessary when ALL of the following criteria are met:

    ® Pain primarily experienced between the upper level of the iliac crests and the gluteal fold (the pain can refer distally, even below the knee)
    ® Clinical findings and imaging studies suggest no other obvious cause of the pain (e.g., central spinal stenosis with neurogenic claudication/myelopathy, foraminal stenosis or disc herniation with concordant radicular pain/radiculopathy, infection, tumor, fracture, pseudoarthrosis, pain related to spinal instrumentation).
    ® Reproduction of pain using at least three (3) of the following provocative tests:
      ¡ Distraction or “Gapping” or FABER/Patrick’s Test
      ¡ Thigh Thrust or Posterior Pelvic Pain Provocational Test
      ¡ Gaenslan’s Test
      ¡ Sacroiliac Joint Compression Test
      ¡ Sacral Thrust or Yeoman’s Test.
    ® Pain persists despite BOTH of the following:
      ¡ A minimum of four (4) weeks of noninvasive conservative therapy (e.g., exercise, physical therapy, chiropractic care, nonsteroidal anti-inflammatory drugs [NSAIDs] and analgesics)
      ¡ Ongoing, active participation in rehabilitative/therapeutic exercise program
A therapeutic sacroiliac joint injection for the treatment of sacroiliac joint pain is considered medically necessary following a diagnostic injection with ≥ 75% reduction in the reported pain.

A repeat therapeutic sacroiliac joint injection for the treatment of sacroiliac joint pain is considered medically necessary following a therapeutic injection with ≥ 75% reduction in the reported pain and BOTH of the following are met:

    ® EITHER of the following:
      ¡ Increase in the individual’s level of function (i.e., return to work)
      ¡ Reduction in the use of pain medication and/or additional medical services such as physical therapy/chiropractic care
    ® A minimum of two months since the prior injection
    CMM 203.4 Non-Indications

    Ultrasound guidance for a sacroiliac joint injection, for any indication, is considered investigational.

    Sacral lateral nerve branch blocks and/or ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered investigational.

    A sacroiliac joint injection is considered not medically necessary for ANY of the following:

      ® Injectates other than anesthetic, corticosteroid, and/or contrast agent
      ® Sacroiliac joint injections performed without fluoroscopic or other alternative guidance, with the exception of ultrasound as noted above
      ® When performed on the same date of service as a facet joint block, epidural steroid injection, or lumbar sympathetic chain block
      ® When performed in isolation (i.e., without the individual participating in an active rehabilitation program, home exercise program, or functional restoration program)
      ® As a subsequent diagnostic block when the initial diagnostic block does not produce a positive response of ≥ 75% pain reduction
      ® Therapeutic sacroiliac joint injections performed at a frequency greater than once every two (2) months for the treatment of sacroiliac pain
      ® More than four (4) injections per SI joint performed within a 12 month period


    CMM-203.5 Procedure Codes
    This guideline relates to the CPT® code set below. Codes are displayed for informational purposes only. Any given code’s inclusion on this list does not necessarily indicate prior authorization is required.
    CPT®
    Code Description/Definition
    27096Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed
    G0259Injection procedure for sacroiliac joint; arthrography
    G0260Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography
    This list may not be all inclusive and is not intended to be used for coding/billing purposes. The final determination of reimbursement for services is the decision of the health plan and is based on the individual’s policy or benefit entitlement structure as well as claims processing rules.


    Medicare Coverage:
    There is no National Coverage Determination (NCD) for Sacroiliac Joint Injections. In the absence of an NCD, coverage decisions are left to the discretion of Local Medicare Carriers. Novitas Solutions, Inc, the Local Medicare Carrier for jurisdiction JL, has not issued a determination for Sacroiliac Joint Injections. Therefore, Medicare Advantage Products will follow the Horizon BCBSNJ Medical Policy for Sacroiliac Joint Injections.

    Medicaid Coverage:

    For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.

    FIDE SNP:

    For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.

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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 Injections
    Sacroiliac Joint Block

    References:
    1. American College of Occupational and Environmental Medicine. Occupational Medicine Practice Guideline, 2nd Ed. 2008.

    2. American Medical Association. Current Procedural Terminology. 2016 Professional Edition.

    3. American Society of Anesthesiologists. Statement on Anesthetic Care During Interventional Pain Procedures for Adults. October 22, 2005, amended October 26, 2016.

    4. Appropriate Use Criteria for Fluoroscopically-Guided Diagnostic and Therapeutic Sacroiliac Interventions: Results from the Spine Intervention Society-Convened Multispecialty Collaborative

    5. Berthelot J, Labat J, Le Goff B, et al. Provocative sacroiliac joint maneuvers and sacroiliac joint block are unreliable for diagnosing sacroiliac joint pain. Joint Bone Spine. 2006;73(1):17-23.

    6. Cheng J, Pope JE, Dalton JE, Cheng O, Bensitel A. Comparative outcomes of cooled versus traditional radiofrequency ablation of the lateral branches for sacroiliac joint pain. Clin J Pain.2013; 29:132-137.

    7. Cohen SP, Hurley RW, Buckenmaier CC 3rd, et al. Randomized placebo-controlled study evaluating lateral branch radiofrequency denervation for sacroiliac joint pain. Anesthesiology.2008; 109:279-288.

    8. Foley B, Buschbacher R: Sacroiliac joint pain: anatomy, biomechanics, diagnosis and treatment. Am J Phys Med Rehabil. 2006;85:997–1006.

    9. Forst S, Wheeler M, Fortin J, Vilensky J. The sacroiliac joint: anatomy, physiology and clinical significance. Pain Physician. 2006;9(1):61-67.

    10. Gunaydin I. Pereira P. Fritz J. et al. Magnetic resonance imaging guided corticosteroid injection of sacroiliac joints in patients with spondylarthropathy. Are multiple injections more beneficial?. Rheumatology International. 2006; 26(5):396-400.

    11. Karabacakoglu A. Karakose S. Ozerbil O. Odev K. Fluoroscopy-guided intraarticular corticosteroid injection into the sacroiliac joints in patients with ankylosing spondylitis. Acta Radiologica. 2002;43(4):425-427.

    12. Kennedy DJ, Engel AJ, Kreiner DS, Nampiaparampil D, Duszynski B, MacVicar J. Fluoroscopically guided diagnostic and therapeutic sacroiliac joint injections: a systematic review. Pain Med 2015; 16: 1500-1518.

    13. King W, Ahmed SU, Baisden J, Patel N, Kennedy DJ, MacVicar J, Duszynski B. Diagnosis and treatment of posterior sacroiliac complex pain: a systematic review with comprehensive analysis of the published data. Pain Med 2015 Feb; 16(2): 257.

    14. Laslett M. Evidence-Based Diagnosis and Treatment of the Painful Sacroiliac Joint. J Man Manip Ther. 2008; 16(3): 142–152.

    15. Ling B. Lee J. Man H. et al. Transverse morphology of the sacroiliac joint: effect of angulation and implications for fluoroscopically guided sacroiliac joint injection. Skeletal Radiology. 2006;35(11):838-846.

    16. Luukkainen R. Nissila M. Asikainen E. Set al. Periarticular corticosteroid treatment of the sacroiliac joint in patients with seronegative spondylarthropathy. Clinical & Experimental Rheumatology. 1999;17(1):88-90.

    17. Luukkainen R. Wennerstrand P. Kautiainen H. et al. Efficacy of periarticular corticosteroid treatment of the sacroiliac joint in non-spondylarthropathic patients with chronic low back pain in the region of the sacroiliac joint. Clinical & Experimental Rheumatology. 2002;20(1):52-54.

    18. McKenzie-Brown A, Shah R, Sehgal N, Everett C. A Systematic Review of Sacroiliac Joint Interventions. Pain Physician. 2005;8;115-125.

    19. MacVicar J, Kreiner DS, Duszynski B, et. al. Appropriate Use Criteria for Fluoroscopically Guided Diagnostic and Therapeutic Sacroiliac Interventions: Results from the Spine Intervention Society Convened Multispecialty Collaborative, Pain Medicine, Volume 18, Issue 11, 1 November 2017, Pages 2081–2095Manchikanti L, Abdi S, Atluri S, et al. An update of comprehensive evidence-based guidelines for interventional techniques of chronic spinal pain: Part II: Guidance and recommendations. Pain Physician. 2013; 16:S49-S283.

    20. Manchikanti L, Staats P, Singh V, et al. Evidence-based practice guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician. 2003;6:3-81.

    21. Mitchell B, MacPhail T, Vivian D, Verrills P, Barnard A. Radiofrequency neurotomy for sacroiliac joint pain: A prospective study. Surgical Science. 2015;6:265-272.

    22. Murakami E. Tanaka Y. Aizawa T. et al. Effect of periarticular and intraarticular lidocaine injections for sacroiliac joint pain: prospective comparative study. Journal of Orthopaedic Science. 2007;12(3):274-280.

    23. Nelemans P, de Bie R, de Vet H, Sturmans F, Injection therapy for subacute and chronic benign low back pain. Cochrane Database Syst Rev. 2000;(2):CD001824.

    24. North American Spine Society (NASS). NASS Coverage Policy Recommendation: Sacroiliac Joint Injections. Copyright © 2015-2017 North American Spine Society

    25. Patel J, Schneider B, Smith C on behalf of SIS Patient Safety Committee. Intrarticular Corticosteroid Injections and hyperglycemia. 10/4/17.

    26. Patel N, Gross A, Brown L, Gekht G. A randomized, placebo-controlled study to assess the efficacy of lateral branch neurotomy for chronic sacroiliac joint pain. Pain Med.2012; 13:383-398.

    27. Pekkafahli M. Kiralp M. Basekim C. et al. Sacroiliac joint injections performed with sonographic guidance. Journal of Ultrasound in Medicine. 2003;22(6):553-559.

    28. Rosenberg J. Quint T. de Rosayro A. Computerized tomographic localization of clinically-guided sacroiliac joint injections. Clinical Journal of Pain. 2000;16(1):18-21.

    29. Schmidt GL, Bhandutia AK, Altman DT. Management of sacroiliac joint pain. J Am Acad Orthop Surg. 2018;26:610-616. doi: 10.5435/JAAOS-D-15-00063.

    30. Schneider B, Rosati R, et al. Challeges in diagnosing sacroiliac joint pain: a narrative review. PMR 11(2019) S 40- 45

    31. Slipman C. Lipetz J. Plastaras C. et al. Fluoroscopically guided therapeutic sacroiliac joint injections for sacroiliac joint syndrome. American Journal of Physical Medicine & Rehabilitation. 2001;80(6):425-432.

    32. Simopoulos TT, Manchikanti L, Gupta S, et al. Systematic review of the diagnostic accuracy and therapeutic effectiveness of sacroiliac joint interventions. Pain Physician. 2015;18:E713-E756.

    33. Stelzer W, Aiglesberger M, Stelzer D, Stelzer V. Use of cooled radiofrequency lateral branch neurotomy for the treatment of sacroiliac joint-mediated low back pain: A large case series. Pain Med. 2013;14:29-35.

    34. Vallejo R, Benyamin R, Kramer J, et al. Pulsed radiofrequency denervation for the treatment of sacroiliac joint syndrome. Pain Med. 2006;7:429-434.

    35. van der Wurff P. Buijs E. Groen G. A multitest regimen of pain provocation tests as an aid to reduce unnecessary minimally invasive sacroiliac joint procedures. Archives of Physical Medicine & Rehabilitation. 2006; 87(1):10-14.

    36. Workloss Data Institute. Official Disability Guidelines. www.worklossdata.com.

    37. Young S. Aprill C. Laslett M. Correlation of clinical examination characteristics with three sources of chronic low back pain. Spine Journal: Official Journal of the North American Spine Society. 2003;3(6):460-465.

    38. Zelle B, Gruen G, Brown S, George S. Sacroiliac joint dysfunction: evaluation and management. Clin J Pain. 2005;21(5):446-455.

    39. Zheng P, Schneider B, et al. Image – guided sacroiliac joint injections: an evidence – based review of best practices and clinical outcomes. PMR 11 (2019) S 98 – S 104.

    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*

      27096
      G0259
      G0260
    HCPCS

    * CPT only copyright 2020 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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