The Plan

Members with chronic pain in the lowest portion of the spine known as the sacrum may qualify for diagnostic and/or therapeutic procedures to further characterize or treat their pain. The sacroiliac (SI) joint refers to the joint between the bones of the sacral spine and the iliac bones of the pelvis. There are two total SI joints, with one on each side of the pelvis. When there is damage or injury to the SI joint or the nerves traversing it, pain can develop in the lower back, buttocks, or can radiate down into the legs.

Pain may be treated with brief rest, ice, heating, and over-the-counter anti-inflammatory medications. In some cases, the symptoms may be chronic in nature and require further treatment, including physical therapy, further oral medications, and potentially injections of medication directly into the joint space. Not all pain in the sacrum or lower back is due to dysfunction of the SI joint, thus there are a number of diagnostic procedures to determine the source of the symptoms. This guideline focuses specifically on injections into SI joint space for both diagnostic and therapeutic purposes.

Definitions

• Sacroiliac joint or SI joint refers to the interface between the fused bones of the sacral spine and the iliac portion of the pelvis. The sacroiliac region is between the top of the iliac crests down to the gluteal folds.
• SI joint pain refers to pain originating from the joint, often characterized by pain in the lower back, buttock, or radiating down into the legs. Not all pain in this area is caused by SI joint dysfunction. SI joint pain often occurs in the absence of any radiologic findings, making diagnosis difficult. There are a number of clinical maneuvers and tests that can be used along with patient history to distinguish SI joint pain from other causes of pain in this region.
• Intra-articular injection refers to an injection within the joint space, often with corticosteroids, anesthetics, or both.
• Peri-articular injection refers to an injection into the posterior ligamentous structures surrounding the joint space.
• Diagnostic injection refers to an injection performed to determine if the cause of the symptoms are due to the suspected joint space. This may be performed prior or concurrent to a therapeutic injection.
• Therapeutic injection refers to an injection performed to treat symptoms at the target joint space.

Clinical Indications

Initial Sacroiliac Intra-Articular Joint Injections

The Plan considers initial sacroiliac joint injections medically necessary when ALL of the following criteria are met:

1. Symptoms are consistent with SI joint pain meeting ALL of the following criteria:

   1. Chronic pain of ≥3 months duration located between the upper iliac crests and the gluteal folds; and
   2. The pain is reproducible with a positive result on AT LEAST 3 of the following clinical provocation tests:
      • Compression Test; or
      • Distraction; or
      • FABER (Flexion, ABduction, External Rotation)/Patrick’s Test; or
      • Gaenslen’s Test; or
      • Posterior Pelvic Pain Provocation Test (Thigh thrust, Posterior shear); or
      • Sacral Thrust or Yeoman’s Test; and
   3. Pain has not responded to at least 6 weeks of conservative therapy, as defined by the following:
   • Trial of appropriate medications (e.g., NSAIDs, analgesics, etc. ); and
   • Physical therapy or other specific interventions tailored to the member’s unique presentation; and
   4. Negative clinical workup for an alternative etiology of the pain such as infection, tumor, fracture, or pain related to prior spinal instrumentation; and
2. The injection contains an anesthetic agent, with or without a corticosteroid agent; and
3. Injection is performed with image-guidance using fluoroscopy or CT; and
4. The member will continue to engage in active pain management program which may consist of oral/topical medications, exercise, physical therapy, psychosocial support, rehabilitation, etc; and

There are no contraindications to SI joint injection present (see below).

Subsequent Sacroiliac Intra-Articular Joint Injections (Continuation of Therapy)

The Plan considers subsequent sacroiliac joint injections medically necessary when ALL of the following criteria are met:

1. The injection contains an anesthetic agent, with or without a corticosteroid agent; and
2. The injection is performed with image-guidance using fluoroscopy or CT; and
3. The member will continue to engage in active pain management program which may consist of oral/topical medications, exercise, physical therapy, psychosocial support, rehabilitation, etc; and
4. The previous injection resulted in at least partial symptomatic relief, defined as at least 50% relief in pain and/or symptoms for the duration of effect of the agent(s) used:
   • Reduction in hours of pain for anesthetic-only injections; and/or
   • Pain relief duration for at least 2 weeks for injections containing both anesthetic and steroid; and
5. At least 2 weeks have passed since the diagnostic injection, or 2 months since the previous therapeutic injection; and
6. No more than 4 injections (per side) are given over a rolling 12-month period; and
7. There are no contraindications to SI joint injection present (see below).

Experimental or Investigational / Not Medically Necessary

SI joint injections for any other indication are considered experimental or investigational. Non-covered indications and procedures include, but are not limited to, the following:

• Radiofrequency ablations for sacroiliac joints are considered experimental or investigational
• Injections performed with ultrasound guidance, as it is considered experimental or investigational
• The use of supplemental anesthesia beyond local anesthetic at the injection site, as it is considered not medically necessary
• Multiple injection types performed in the same visit (e.g., epidural, facet joint, sympathetic block, etc), as it is considered not medically necessary
• Injections outside of the joint space (e.g., sacral nerve root blocks, peri-articular injections), as it is considered experimental or investigational
• Injections in the presence of any of the following contraindications, as it is considered not medically necessary:
  • Active systemic or local infection (e.g., septic joint, osteomyelitis, skin infection at or around the proposed injection site)
  • Allergies to fluoroscopy contrast, anesthetics, or steroid formulation
  • Local malignancy affecting injection site or SI joint
  • Poorly controlled diabetes or blood pressure
  • Pregnancy
  • Severe bleeding disorder, platelets <50,000
  • Unstable angina
  • Unstable or severe congestive heart failure