Back Pain - Sacroiliac Joint and Coccydynia Treatments Form

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Back Pain: Sacroiliac and Coccydynia Treatment Medical Guideline

Service: Back Pain: Sacroiliac and Coccydynia Treatment

PUM 250-0024-1706

Medical Guideline Committee Approval Q2-06/2025 Effective Date 09/01/2025

Related Medical Guidelines:

• Back and Neck Pain Procedures: Epidural Injections Medical Guideline • Back and Nerve Pain: Radiofrequency Ablation, Facet Joint, and other Injections Medical Guideline • Non-covered Services and Procedures Medical Guideline

Coverage for Sacroiliac and coccydynia treatment may vary across plans. Refer to the member’s benefit plan document for coverage details.

Description:

Sacroiliac (SI) joint injection is an injection of local anesthetic and/or a steroid into the articular space between the spinal column and pelvis.

Coccydynia/coccydynia pain in the coccyx (tailbone), is most commonly the result of falling backwards and landing in a sitting position. While most cases resolve without medical care or with conservative management, a minority of individuals may develop chronic coccyx pain.

Indications of Coverage:

A. Sacroiliac joint injection is considered medically necessary when ALL of the following conditions (1 through 4) are met:

1. Chronic back and buttock pain symptoms for at least three (3) months.

2. Physical exam findings consistent with sacroiliac joint (SIJ) symptoms (e.g., positive thigh thrust test, distraction test, compression test, Flexion Abduction, and External Rotation test, [FABER] also known as “Patrick’s test”, and/or Gaenslen’s Maneuver indicate sacroiliac joint cause). If bilateral injections are requested, the symptoms and physical exam findings, must be bilateral.

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3. Within the last 12 months, the individual has completed a 6-week trial of medications such as anti-inflammatories, muscle relaxants, analgesics, opioids, gabapentin, and pregabalin.

4. Within the last 12 months, the individual has completed a 6-week trial of physical therapy (PT) or chiropractic manipulations that have been performed after the current episode of symptoms started and directed toward the sacroiliac joint symptoms/dysfunction.

   Note: Documentation of therapy administered by a Certified Athletic Trainer or regular participation in a program such as the Arthritis Foundation Exercise Program may also meet medical criteria for therapy.

   If the above Indications of Coverage (section A, 1 through 4) are met, an initial sacroiliac joint injection will be allowed.

   Subsequent Sacroiliac Injections: Repeat sacroiliac injection within 12 months of the prior injection at the same location for the same specific condition is considered medically necessary when ALL of the following (1 and 2 below) are met:

5. The previous injection had decreased pain and symptoms by at least 50 percent, but the pain or decreased functional status has returned.

6. At least four (4) weeks have passed since the previous injection.

   Sacroiliac Joint Injection Limit: A maximum of four (4) sacroiliac joint injections in a 12- month period * (including intra-articular steroid injections and periarticular injections), regardless of location (left or right), whether diagnostic or therapeutic, will be considered medically necessary when criteria are met for each injection. Services in excess of these thresholds will require Medical Director review on a case by case basis.

   *A year is defined as the 12-month period starting from the date of service of the first approved injection.

   B. Coccyx injection is considered medically necessary when ALL of the following conditions (1 through 5 below) are met:

7. Chronic coccyx (tailbone) pain for at least three (3) months.

8. Physical exam findings show focal external palpation of the coccyx reproduces symptoms locally without pain, erythema or swelling in the surrounding area.

9. Within the last six months, the individual has completed a 6-week trial of medications such as anti-inflammatories, muscle relaxants, analgesics, opioids, gabapentin, and pregabalin.

10. Within the last six months, the individual has completed a 6-week trial of physical therapy (PT) or chiropractic manipulations that were performed after the current

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episode of symptoms started and directed toward the coccygeal joint symptoms/dysfunction.

Note: Documentation of therapy administered by a Certified Athletic Trainer or regular participation in a program such as the Arthritis Foundation Exercise Program may also meet medical criteria for therapy.

5. Within the last six months, the individual has completed a 6-week trial of a donut or wedge cushion.

   If the above Indications of Coverage (letter B, 1 through 5) are met, an initial coccyx injection will be allowed.

   Repeat Coccyx Injection: If the individual has experienced a decrease in pain symptoms of at least 50% for at least one (1) week following the initial coccyx injection (and the member health plan allows), a second injection may be approved. The second coccyx injection must be given at least one (1) month after the previous injection and documentation must show there has been return of pain or functional disability related to the coccyx.

   Coccyx Injection Limit: A maximum of two (2) coccyx injections in a year* is considered medically necessary when criteria are met for each injection. Services in excess of these thresholds will require Medical Director review on a case by case basis.

   *A year is defined as the 12-month period starting from the date of service of the first approved injection.

   C. Sacroiliac joint fusion (arthrodesis) procedures are considered medically necessary for any of the following:

6. As an adjunct to sacrectomy procedures related to tumors involving the sacrum

7. As an adjunct to surgical treatment of sacroiliac joint infections

8. For treatment of severe trauma (e.g., pelvic ring fracture, acetabular fracture, spinopelvic dissociation)

9. During surgical procedures such as correction of scoliosis extending to the ileum or when performed as part of a multi-segmental fusion

   D.
   Percutaneous Minimally Invasive Sacroiliac Joint Fusion (Arthrodesis) procedures

   Percutaneous Minimally Invasive Sacroiliac Joint Fusion (Arthrodesis) procedures

   using an FDA-approved implant (iFuse, Simmetry Sacroiliac Joint Fusion System

   [Zyga Technology Inc.], SI-LOK Sacroiliac Joint Fixation System [Globus Medical

   Inc.], Navigation Instruments, ExcelsiusGPS Instruments [Globus Medical Inc.],

   Rialto SI Fusion System [Medtronic Sofamor Danek], Integrity-SI Fusion System

   [OsteoCentric Technologies]), or alternatively by placement of bone allografts

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placed across the SI joint and intended to promote bone fusion is considered medically

necessary for the treatment of low back/buttock pain resulting from degenerative

sacroiliitis or sacroiliac joint dysfunction or syndrome when ALL of the following

criteria are met:

1. Chronic low back pain due to sacroiliac joint dysfunction.

2. Failure of three consecutive months of conservative treatment (to include activity

   modification and/or bracing, medication, and Physical Therapy) within the past 12-

   month period.

3. Imaging studies exclude the presence of other causes for SIJ dysfunction/pain,

   including but not limited to:

   • Acute fracture, or stress/insufficiency fracture • Concomitant hip osteoarthritis • Destructive SIJ lesions (infection, tumors) • Inflammatory arthropathy • Lumbar spine degenerative conditions or neural compression

    Alternatively, if any of these above conditions are present, the provider must document concomitant disease affecting the SI joint and another region (e.g., Lumbar Spine).

4. Positive response (reproduction of the individual’s typical SIJ pain) to at least ONE of

   the following provocative tests/maneuvers: • Compression test • Distraction test • FABER test (also referred to as Patrick’s test) • Gaenslen’s test • Thigh thrust test (also referred to as posterior pelvic pain provocation)

5. Positive response to two diagnostic image guided SIJ injections, at intervals of no

   sooner than two weeks (a positive response is defined as at least 50% reduction in pain

   and/or symptoms).

   Limitations of Coverage:

   Benefit Limitations: Please note that in listing services or examples, when we say “this includes,” it is not our intent to limit the description to that specific list. When we do intend to limit a list of services or examples, we state specifically that the list “is limited to.”

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A. Review health plan and endorsements for exclusions and prior authorization or benefit requirements.

B. If requested/used for a condition or diagnosis other than is listed in the Indications of Coverage, it will be considered experimental, investigational, and unproven to affect health outcomes.

C. If requested/used for a condition or diagnosis that is listed in the Indications of Coverage; but the criteria are not met, it will be considered not medically necessary.

D. If the previous sacroiliac joint injection or coccyx injection was not effective (did not reduce pain by at least 50%), a subsequent injection will be considered not medically necessary.

E. A second coccyx injection provided less than one (1) month after the initial injection will be considered not medically necessary. Services in excess of this threshold will require Medical Director review on a case by case basis.

F. If the use of fluoroscopic or computed tomography (CT) guidance is not documented, the sacroiliac joint injection will be considered unproven to affect health outcomes.

G. Ultrasound treatment, short wave diathermy, peripheral nerve field stimulation, and transcutaneous nerve stimulation for treatment of coccydynia will be considered experimental, investigational, and unproven to affect health outcomes.

H. More than four (4) sacroiliac joint injections (including intra-articular steroid injections, lateral sacral and periarticular injections), regardless of location (left or right), whether diagnostic or therapeutic, in a 12-month period will be considered not medically necessary. Services in excess of these thresholds will require Medical Director review on a case by case basis.

I. Performing a sacroiliac joint arthrogram in conjunction with a sacroiliac joint injection is considered integral to the procedure and will not be reimbursed separately.

J. Nerve blocks (e.g., lumbar and sacral medial branch blocks and/or lateral branch blocks or lumbar L5 dorsal ramus block) for diagnosis or treatment of sacroiliac (SI) joint pain or pain resulting from SI joint derangement or dysfunction will be considered experimental, investigational, and unproven to affect health outcomes.

K. Sacroiliac joint ablation (includes water cooled, pulsed, and radiofrequency/thermal ablation), sacral branch neuroablations (e.g., lateral sacral branch neuroablation and lumbar L5 dorsal ramus ablation) are considered experimental or investigational for management of back/buttocks pain or SI joint dysfunction.

L. Injection of a caustic agent such as phenol or alcohol into a sacroiliac joint will considered experimental, investigational, and unproven to affect health outcomes.

M. Percutaneous sacroplasty will be considered experimental, investigational, and unproven to affect health outcomes.

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N. If more than one type of pain treatment is requested/performed on the same day, only one (1) type will be considered medically necessary at the discretion of the health plan. The other will be considered not medically necessary. Services in excess of this threshold will require Medical Director review on a case by case basis.

O. Ganglion Impar Block or Radiofrequency Thermocoagulation for the Treatment of Chronic Coccydynia will be considered experimental, investigational, and unproven to affect health outcomes.

P. Stem cells and/or Platelet-rich plasma (PRP) injections are considered experimental, investigational, and unproven to affect health outcomes.

Q. Minimally invasive posterior sacroiliac joint fusion for management of sacroiliac joint pain is considered experimental, investigational, and unproven to affect health outcomes.

Documentation Required:

• Standard Written Order (SWO), prescribed by a qualified healthcare provider concerning the member’s diagnosis.
• Medical record information (including continued need/use if applicable) and medical necessity. • Correct coding for the item/service that meets all the coding guidelines.

Disclaimer: This guideline is for informational purposes only and does not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may or may not provide coverage for all services listed in this guideline. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs medical guideline in all their coverage determinations. Contact customer services as listed on the member card for specific plan, benefit, and network status information.

Medical guidelines are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in administering health benefits. This medical guideline and MCG guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider. To obtain additional information about MCG, email medical.policies@wpsic.com. Coverage of all services is subject to medical necessity and services deemed experimental, investigational, and/or unproven are therefore not considered medically necessary under the terms of the clinical guidelines and will not be covered.

Sacroiliac and Coccydynia Treatments are considered medically necessary only when indicated by the most current medical references and specialty society guidelines, such as MCG, NCCN, etc.

State mandates, laws or benchmark supersede this medical guideline.

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Guideline Review History:

Implemented 08/21/17, 10/01/18, 10/01/19, 09/01/20, 03/01/21, 06/01/21, 06/01/22, 09/01/23, 06/01/24, 09/01/25 Medical Guideline Committee Approval 09/12/14, 09/11/15, PUM 250-0024 retired 06/03/16 effective 09/30/16 to Radiofrequency Ablation, Facet Joint Injection, and others. Coccydynia Injections retired to Back Pain Procedures – Epidural Injections. Guideline reinstated 06/16/17 as PUM 250- 0024-1706, 06/15/18, 05/31/19, 05/28/20, 02/25/21, 05/27/21, 05/26/22, 05/17/23, 05/30/24, 06/26/25 Reviewed 09/12/14, 09/11/15, 06/03/16, 06/16/17, 06/15/18, 05/31/19, 05/28/20, 05/27/21, 05/26/22, 05/17/23, 05/30/24, 06/26/25

Approved by the Medical Director

Codes: The following codes for treatments and procedures applicable to this document are included below for informational purposes.

Code Description 27096 INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED 27278 ARTHRODESIS, SACROILIAC JOINT, PERCUTANEOUS WITH IMAGE GUIDANCE, INCLUDING PLACEMENT OF INTERA ARTICULARE IMPLANTN (S) (E.G., BONE ALLOGRAFTS), SYNTHETIC DEVICE(S) WITHOUT PLACEMENT OF TRANSFIXATION 27279 ARTHRODESIS, SACROILIAC JOINT, PERCUTANEOUS OR MINIMALLY INVASIVE (INDIRECT VISUALIZATION), WITH IMAGE GUIDANCE, INCLUDES OBTAINING BONE GRAFT WHEN PERFORMED, AND PLACEMENT OF TRANSFIXING DEVICE 27280 ARTHRODESIS, OPEN, SACROILIAC JOINT, INCLUDING OBTAINING BONE GRAFT, INCLUDING INSTRUMENTATION, WHEN PERFORMED 64451 INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY) 64625 RADIOFREQUENCY ABLATION, NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY) 64635 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT 64636 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

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C1737 JOINT FUSION AND FIXATION DEVICE(S), SACROILIAC AND PELVIS, INCLUDING ALL SYSTEM COMPONENTS (IMPLANTABLE) G0259 INJECTION PROCEDURE FOR SACROILIAC JOINT; ARTHROGRAPHY G0260 INJECTION PROCEDURE FOR SACROILIAC JOINT; PROVISION OF ANESTHETIC, STEROID AND/OR OTHER THERAPEUTIC AGENT, WITH OR WITHOUT ARTHROGRAPHY 01593ZZ DESTRUCTION OF LUMBAR PLEXUS, PERCUTANEOUS APPROACH 015A3ZZ DESTRUCTION OF LUMBOSACRAL PLEXUS, PERCUTANEOUS APPROACH 015Q3ZZ DESTRUCTION OF SACRAL PLEXUS, PERCUTANEOUS APPROACH 0QB20ZZ EXCISION OF RIGHT PELVIC BONE, OPEN APPROACH 0QB30ZZ EXCISION OF LEFT PELVIC BONE, OPEN APPROACH 0SG734Z FUSION OF RIGHT SACROILIAC JOINT WITH INTERNAL FIXATION DEVICE, PERCUTANEOUS APPROACH 0SG737Z FUSION OF RIGHT SACROILIAC JOINT WITH AUTOLOGOUS TISSUE SUBSTITUTE, PERCUTANEOUS APPROACH 0SG73JZ FUSION OF RIGHT SACROILIAC JOINT WITH SYNTHETIC SUBSTITUTE, PERCUTANEOUS APPROACH 0SG73KZ FUSION OF RIGHT SACROILIAC JOINT WITH NONAUTOLOGOUS TISSUE SUBSTITUTE, PERCUTANEOUS APPROACH 0SG834Z FUSION OF LEFT SACROILIAC JOINT WITH INTERNAL FIXATION DEVICE, PERCUTANEOUS APPROACH 0SG837Z FUSION OF LEFT SACROILIAC JOINT WITH AUTOLOGOUS TISSUE SUBSTITUTE, PERCUTANEOUS APPROACH 0SG83JZ FUSION OF LEFT SACROILIAC JOINT WITH SYNTHETIC SUBSTITUTE, PERCUTANEOUS APPROACH 0SG83KZ FUSION OF LEFT SACROILIAC JOINT WITH NONAUTOLOGOUS TISSUE SUBSTITUTE, PERCUTANEOUS APPROACH 3E0T3BZ INTRODUCTION OF ANESTHETIC AGENT INTO PERIPHERAL NERVES AND PLEXI, PERCUTANEOUS APPROACH 3E0T3GC INTRODUCTION OF OTHER THERAPEUTIC SUBSTANCE INTO PERIPHERAL NERVES AND PLEXI, PERCUTANEOUS APPROACH 3E0U33Z INTRODUCTION OF ANTI-INFLAMMATORY INTO JOINTS, PERCUTANEOUS APPROACH 3E0U3BZ INTRODUCTION OF ANESTHETIC AGENT INTO JOINTS, PERCUTANEOUS APPROACH 3E0U3GC INTRODUCTION OF OTHER THERAPEUTIC SUBSTANCE INTO JOINTS, PERCUTANEOUS APPROACH 3E0U3KZ INTRODUCTION OF OTHER DIAGNOSTIC SUBSTANCE INTO JOINTS, PERCUTANEOUS APPROACH