Diagnosis and Treatment of Sacroiliac Joint Pain Form

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Medical Policy Number: 6.01.VT23

Diagnosis and Treatment of Sacroiliac Joint Pain
Corporate Medical Policy File Name: Diagnosis and Treatment of Sacroiliac Joint Pain
File Code: 6.01.VT23 Origination: 11/26/2018 Last Review: 03/2025 Next Review: 03/2026 Effective Date: 07/01/2025

Description/Summary Sacroiliac joint arthrography using fluoroscopic guidance with injection of an anesthetic has been explored as a diagnostic test for sacroiliac joint pain. Duplication of the individual’s pain pattern with the injection of contrast medium suggests a sacroiliac etiology, as relief of chronic back pain with injection of local anesthetic. Treatment of sacroiliac joint pain with corticosteroids, radiofrequency ablation (RFA), stabilization, or minimally invasive arthrodesis has also been explored. Policy Coding Information Click the links below for attachments, coding tables & instructions. Attachment I- CPT® Coding Table & Instructions

When a service may be considered medically necessary

Injection of anesthetic for the purpose of diagnosing sacroiliac joint pain may be considered medically necessary when the following criteria have been met:

• Pain has failed to respond to 3 months of conservative management, which may consist of therapies such as nonsteroidal anti-inflammatory medications, acetaminophen, manipulation, physical therapy, and a home exercise program; AND • Dual (controlled) diagnostic blocks with 2 anesthetic agents with differing duration of action are used; AND • The injections are performed under imaging guidance

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Medical Policy Number: 6.01.VT23

Injection of corticosteroid may be considered medically necessary for the treatment of sacroiliac joint pain when the following criteria have been met: • Pain has failed to respond to 3 months of conservative management, which may consist of therapies such as nonsteroidal anti-inflammatory medications, acetaminophen, manipulation, physical therapy, and a home exercise program; AND • The injection is performed under imaging guidance; AND • No more than 3 injections are given in a rolling 12 month period (NOTE: 3 is a combined limit)

Open, percutaneous, or minimally invasive fixation/fusion/stabilization of the sacroiliac joint using transiliac placement of a titanium triangular implant (e.g. iFuse) may be considered medically necessary when ALL of the following criteria have been met:

• Pain is at least 5 on a 0 to 10 rating scale that impacts quality of life or limits activities of daily living; AND • There is an absence of generalized pain behavior (eg, somatoform disorder) or generalized pain disorders (eg, fibromyalgia); AND • Individuals have undergone and failed a minimum 6 months of intensive non- operative treatment that must include medication optimization, activity modification, bracing, and active therapeutic exercise targeted at the lumbar spine, pelvis, sacroiliac joint, and hip, including a home exercise program; AND • Pain is caudal to the lumbar spine (L5 vertebra), localized over the posterior sacroiliac joint, and consistent with sacroiliac joint pain; AND • A thorough physical examination demonstrates localized tenderness with palpation over the sacral sulcus (Fortin’s point) in the absence of tenderness of similar severity elsewhere; AND • There is a positive response to a cluster of 3 provocative tests (eg, thigh thrust test, compression test, Gaenslen sign, distraction test, Patrick test, posterior provocation test); AND • Diagnostic imaging studies include ALL of the following:

• Imaging (plain radiographs and computed tomography or magnetic resonance imaging) of the sacroiliac joint excludes the presence of destructive lesions (eg, tumor, infection) or inflammatory arthropathy of the sacroiliac joint; AND
• Imaging of the pelvis (anteroposterior plain radiograph) rules out concomitant hip pathology; AND
• Imaging of the lumbar spine (computed tomography or magnetic resonance imaging) is performed to rule out neural compression or other degenerative condition that can be causing low back or buttock pain; AND
• Imaging of the sacroiliac joint indicates evidence of injury and/or degeneration; AND • There is at least a 75% reduction in pain for the expected duration of the anesthetic used following an image-guided, contrast-enhanced intra- articular sacroiliac joint injection on 2 separate occasions; AND

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Medical Policy Number: 6.01.VT23

• A trial of a therapeutic sacroiliac joint injection (ie, corticosteroid injection) has been performed on at least once.

When a service is considered investigational

Fusion/stabilization of the sacroiliac joint for the treatment of back pain presumed to originate from the sacroiliac joint is considered investigational under all other conditions and with any other devices not listed above.

Radiofrequency denervation of the sacroiliac joint is considered investigational.

Arthrography of the sacroiliac joint is considered investigational. Policy Guidelines This policy does not address the treatment of sacroiliac joint pain due to infection, trauma, or neoplasm. This technically demanding procedure should only be done by surgeons who have specific training and expertise in minimally invasive sacroiliac joint fusion surgery for chronic sacroiliac joint pain and who regularly use image -guidance for implant placement. Conservative nonsurgical therapy for the duration specified should include the following: • Use of prescription strength analgesics for several weeks 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, AND • Participation in at least 6 weeks of physical therapy (including active exercise) or documentation of why the individual could not tolerate physical therapy, AND • Evaluation and appropriate management of associated cognitive, behavioral, or addiction issues, AND • Documentation of individual’s compliance with the preceding criteria. A successful trial of controlled diagnostic lateral branch blocks consists of 2 separate positive blocks on different days with local anesthetic only (no steroids or other drugs), or a placebo-controlled series of blocks, under fluoroscopic guidance, that has resulted in a reduction in pain for the duration of the local anesthetic used (eg, 3 hours longer with bupivacaine than lidocaine). There is no consensus on whether a minimum of 50% or 75% reduction in pain would be required to be considered a successful diagnostic block, although evidence that supported a criterion standard of 75% to 100% reduction in pain with dual blocks. No therapeutic intra-articular injections (ie, steroids, saline, other substances) should be administered for a period of at least 4 weeks before the diagnostic

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Medical Policy Number: 6.01.VT23

The diagnostic blocks should not be conducted under intravenous sedation unless specifically indicated (eg, the individual is unable to cooperate with the procedure).

Clinical Input Clinical input was provided by the following specialty societies and physician members identified by a specialty society or health system: • American Association of Neurological Surgeons/Congress of Neurological Surgeons (AANS/CNS) • American Pain Society (APS) • American Society of Regional Anesthesia and Pain Medicine (ASRA)a • International Society for the Advancement of Spine Surgery (ISASS)b • North American Spine Society/American Academy of Orthopaedic Surgeons (NASS/AAOS)

(a)Indicates that information was not provided regarding conflicts of interest related to the topic where clinical input is being sought. (b) Indicates that conflicts of interest related to the topic where clinical input is being sought were identified by this respondent.

Clinical input provided by the specialty society at an aggregate level is attributed to the specialty society. Clinical input provided by a physician member designated by the specialty society is attributed to the individual physician and is not a statement from the specialty society. Specialty society and physician respondents participating in the Evidence Street® clinical input process provide review, input, and feedback on topics being evaluated by Evidence Street. However, participation in the clinical input process by a specialty society and/or physician member designated by the specialty society or clinical health system does not imply an endorsement or explicit agreement with the Evidence Opinion published by BCBSA or any Blue Plan.

Reference Resources

1. Blue Cross and Blue Shield Association MPRM 6.01.23 - Diagnosis and Treatment of Sacroiliac Joint Pain. Last Reviewed 12/2024. Accessed 02/2025.

   Document Precedence Blue Cross and Blue Shield of Vermont (Blue Cross VT) Medical Policies are developed to provide clinical guidance and are based on research of current medical literature and review of common medical practices in the treatment and diagnosis of disease. The applicable group/individual contract and member certificate language, or employer’s benefit plan if an ASO group, determines benefits that are in effect at the time of service. Since medical practices and knowledge are constantly evolving, Blue Cross VT reserves the right to review and revise its medical policies periodically. To the extent that there may be any conflict between medical policy and contract/employer benefit

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Medical Policy Number: 6.01.VT23

plan language, the member’s contract/employer benefit plan language takes precedence. Audit Information Blue Cross VT reserves the right to conduct audits on any provider and/or facility to ensure compliance with the guidelines stated in the medical policy. If an audit identifies instances of non-compliance with this medical policy, Blue Cross VT reserves the right to recoup all non-compliant payments. Administrative and Contractual Guidance Benefit Determination Guidance Prior approval may be required and benefits are subject to all terms, limitations and conditions of the subscriber contract.

Incomplete authorization requests may result in a delay of decision pending submission of missing information. To be considered compete, see policy guidelines above.

NEHP/ABNE members may have different benefits for services listed in this policy. To confirm benefits, please contact the customer service department at the member’s health plan.

Federal Employee Program (FEP): Members may have different benefits that apply. For further information please contact FEP customer service or refer to the FEP Service Benefit Plan Brochure. It is important to verify the member’s benefits prior to providing the service to determine if benefits are available or if there is a specific exclusion in the member’s benefit.

Coverage varies according to the member’s group or individual contract. Not all groups are required to follow the Vermont legislative mandates. Member Contract language takes precedence over medical policy when there is a conflict.

If the member receives benefits through an Administrative Services Only (ASO) group, benefits may vary or not apply. To verify benefit information, please refer to the member’s employer benefit plan documents or contact the customer service department. Language in the employer benefit plan documents takes precedence over medical policy when there is a conflict. Policy Implementation/Update information

04/2015 Adoption of BCBSA medical policy #06.01.23 for the Diagnosis and Treatment of Sacroiliac Joint Pain. Approved by MPC- 04/2015. 04/2017 External feedback provided. Updated criteria for medically necessary SI Joint fusion and investigational based on NASS coverage recommendations. Clarified number of injections per year and per side.

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Medical Policy Number: 6.01.VT23

11/2018 Updated to reflect language of BCBSA medical policy 06.01.23 Last reviewed November 2018. Policy statements remain unchanged.ICD-10- CM Coding table updated. 07/2020 References reviewed. Policy formatting. No change to policy statement intent. Added code 64451 requires prior approval. Code G0259 is investigational. 07/2021 Policy reviewed. Minor formatting changes. No changes to policy statement. 07/2022 Reviewed at HPC 07/18/2022 with the following summary of changes: Policy reviewed. Reference updated. Minor addition of transiliac and iFuse as example of fixation hardware added to Policy statement. No change to Policy intent. Code G0259 requires prior approval effective 05/01/2022 per prior approval list- updated coding table in medical policy. Code 64625 was added to coding table as investigational to align with corporate investigational medical policy. Updated ICD-10-CM coding table. 12/2022 Adaptive Maintenance Effective 01/01/2023: Added code 0775T as investigational to coding table. Revised code descriptor 27280 06/2023 Policy reviewed. No change to policy statement. Minor changes for clarity and consistency. Adaptive Maintenance Effective 07/01/2023: Added code 0809T as investigational to coding table. 12/2023 Adaptive Maintenance Effective 01/01/2024: Deleted codes 0775T, 0809T. Added code 27278 as requiring PA. 02/2024 Policy reviewed. No change to policy statement. Reference updated. Coding table procedure codes updated to remove prior approval on code 27278 and add the code as investigational. ICD-10-CM table removed. 03/2025 Policy reviewed. No change to policy statement. Reference updated.

Eligible providers Qualified healthcare professionals practicing within the scope of their license(s).

Approved by Blue Cross VT Medical Directors

Tom Weigel, MD, MBA Vice President & Chief Medical Officer

Tammaji P. Kulkarni, MD Senior Medical Director

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Medical Policy Number: 6.01.VT23

Attachment I CPT® Coding Table & Instructions

Code Type Number Description Policy Instructions The following codes may be considered medically necessary when applicable criteria have been met CPT® 27096 Injection procedure for sacroiliac joint, anesthetic/ steroid, with image guidance (fluoroscopy or CT) including arthrography when performed. Prior Approval Not Required CPT ® 27278 Percutaneous sacroiliac joint arthrodesis, including placement of intra-articular implant, without placement of transfixation device Investigational
CPT® 27279 Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device Prior Approval Required CPT® 27280 Arthrodesis, open sacroiliac joint including bone graft, including instrumentation, when performed Prior Approval Required CPT® 64451 Injection(s), anesthetic agent(s) and/or steroid; nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography) Prior Approval Required CPT® 64625 Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography) Investigational HCPCS G0259 Injection procedure for sacroiliac joint; arthrography Prior Approval Required
HCPCS G0260 Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography No Prior Approval Required The following code is unlisted and requires clinical documentation at time of claims submission. Clinical documentation will be reviewed and coverage determination will be made by a medical director. CPT® 27299 Unlisted procedure, pelvis or hip joint