Sunflower Health Plan Sacroiliac Joint Interventions for Pain Management (PDF) Form

Treatment for sacroiliac joint (SIJ) dysfunction is usually conservative (non-surgical) and focuses on trying to restore normal motion in the joint. In patients who have failed to respond to conservative therapy, an SIJ injection can be helpful for both diagnostic and therapeutic purposes. SIJ injections into the synovial sac of the SIJ may provide immediate and significant pain relief. Policy/Criteria It is the policy of health plans affiliated with Centene Corporation® that invasive pain management procedures performed by a physician are medically necessary when the relevant criteria are met and the patient receives only one procedure per visit, with or without radiographic guidance. I. Sacroiliac joint injections are medically necessary for the following indications: A. One diagnostic or therapeutic sacroiliac joint (SIJ) injection for SIJ pain, all of the following: 1. Somatic or nonradicular low back and lower extremity pain below the level of L5 vertebra that interferes with activities of daily living (ADLs) for at least 3 months; 2. Tenderness by palpation present over SIJ; 3. There is a positive response to at least three SIJ pain provocation tests (distraction, compression, thigh thrust, Gaenslen’s, Patrick’s test/FABER test, or sacral thrust); 4. The member/enrollee has failed to respond to conservative therapy including all of the following: a. ≥ 6 weeks chiropractic, physical therapy or prescribed home exercise program; b. Nonsteroidal anti-inflammatory drugs (NSAIDs) ≥ 3 weeks or NSAIDs contraindicated or not tolerated; c. ≥ 6 weeks activity modification; 5. Clinical findings and imaging studies, when available, lack obvious evidence for disc- related or facet joint pain; 6. No other possible diagnosis is more likely. B. A second diagnostic or confirmatory sacroiliac joint injection when pain was improved by at least 75% after the first diagnostic SIJ injection and at least 2 weeks have passed since the initial injection. C. Subsequent therapeutic SIJ injections for recurrence of pain, all of the following: 1. Initial therapeutic injection(s) led to ≥ 50% relief and functional improvement for at least 2 months; Page 1 of 8 CLINICAL POLICY Sacroiliac Joint Interventions 2. Request is for SIJ administered for temporary relief of lower back pain in conjunction with other noninvasive treatment methods (e.g., to participate in physical therapy), and not as a stand-alone therapy; 3. SIJ injection is given at intervals at least 2 months apart; 4. Less than 4 therapeutic SIJ injections have been given at the same site in the last 12 months. II. It is the policy of health plans affiliated with Centene Corporation that if pain does not improve by ≥ 75% after the second diagnostic SIJ injection, subsequent SIJ injections are not medically necessary because effectiveness has not been established. III.It is the policy of health plans affiliated with Centene Corporation that continuation of injections beyond 12 months is considered not medically necessary because effectiveness and safety have not been established. When more definitive therapies cannot be tolerated or provided, consideration will be made on a case by case basis. IV. It is the policy of health plans affiliated with Centene Corporation that sacroiliac nerve blocks are considered not medically necessary because effectiveness has not been established. V. It is the policy of health plans affiliated with Centene Corporation that radiofrequency neurotomy (conventional, cooled, and pulsed) of the SIJ is considered not medically necessary because effectiveness has not been established. High-quality studies are lacking for conventional and pulsed radiofrequency neurotomy of the SIJ. For cooled radiofrequency neurotomy, additional well-designed studies are needed to evaluate effectiveness. Background Sacroiliac Joint Injections Treatment for sacroiliac joint dysfunction is usually conservative (non-surgical) and focuses on trying to restore normal motion in the joint. In patients who have failed 4 to 6 weeks of a comprehensive exercise program, local icing, mobilization/manipulation and NSAIDs, an SIJ injection can be helpful for both diagnostic and therapeutic purposes. SIJ injections into the synovial sac of the SIJ may provide immediate and significant pain relief. Adding a steroid to the solution injected may help to reduce any inflammation that may exist within the joint(s) and result in a prolonged period of freedom from pain.8 A study by Visser et al. evaluated the effect of manual therapy and physiotherapy versus SIJ injection for low back and leg pain using a single-blinded randomized trial of treatment for 51 patients with SIJ-related leg pain. The effect of the treatment was evaluated after 6 and 12 weeks. Manual therapy had a significantly better success rate than physiotherapy (p = 0.003). The authors concluded in the small single-blinded prospective study, manual therapy appeared to be the choice of treatment for patients with SIJ-related leg pain.1 A second choice of treatment to be considered is an intra-articular injection.1,22 Page 2 of 8 CLINICAL POLICY Sacroiliac Joint Interventions SIJ Radiofrequency Neurotomy A growing number of studies have assessed the effect of treatment with radiofrequency denervation on SIJ pain, with mixed results. Radiofrequency denervation, also known as RFA or radiofrequency neurotomy, describes the use of radiofrequency energy to stop the transmission of pain signals to the central nervous system.5 One study found no difference between conventional radiofrequency ablation (RFA) and a sham treatment on pain relief.2 A 2017 publication of 3 randomized controlled trials of 681 participants with chronic low back pain found no statistically significant improvement in pain from treatment with a standardized exercise program plus RFA, versus the standardized exercise program alone.3 A systematic review of 12 randomized controlled trials measuring the efficacy of radiofrequency neurotomy to manage chronic low back pain showed moderate evidence for both short-term and long-term improvement.23 Ho and colleagues noted that radiofrequency denervation of the sacroiliac joint (SIJ) have been inconsistent because the variable sensory supply to the SIJ is difficult to disrupt completely using conventional ablation. The authors concluded that denervation showed long- term effectiveness for up to two years in the treatment of SIJ pain. However, there are limitations of this study included with small sample size with a retrospective review with no placebo-control or sham-control group.24 The American Society of Interventional Pain Physicians 2013 guidelines rate the evidence for cooled RFA as fair, and limited for conventional and pulsed RFA.5 The North American Spine Society (NASS) guidelines indicate that consideration can be given to cooled RFA of the sacral lateral branch nerves and dorsal ramus of L5 for patients with sacroiliac joint pain diagnosed with dual diagnostic blocks. Additional randomized trials are required to compare the various nerve ablation techniques of the lateral branch nerves for sacroiliac joint pain.5,22 Coding Implications This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2020, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services. CPT Code that supports coverage criteria CPT® Codes 27096 Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed CPT code that does not support coverage criteria Page 3 of 8 CLINICAL POLICY Sacroiliac Joint Interventions CPT® Codes 64451 64625 Injection(s), anesthetic agent(s) and/or steroid; nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography) Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography) HCPCS code that supports coverage criteria HCPCS Codes G0260 Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography - ICD-10-CM diagnosis codes that support coverage criteria + Indicates a code requiring an additional character - ICD 10 CM Code M43.08 M46.1 M47.818 Spondylolysis, sacral and sacrococcygeal region Sacroiliitis, not elsewhere classified Spondylosis without myelopathy or radiculopathy, sacral and sacrococcygeal region Sacrococcygeal disorders, not elsewhere classified Other specified dorsopathies, lumbosacral region Other specified dorsopathies, sacral and sacrococcygeal region Sciatica M53.3 M53.87 M53.88 M54.30 through M54.32 M54.40 through M54.42 M54.5 M54.89 M54.9 Lumbago with sciatica Low back pain Other dorsalgia Dorsalgia, unspecified Reviews, Revisions, and Approvals Policy split from CP.MP.118 Injections for Pain Management. Minor rewording for clarity. Clarified II. by adding “ ≥ 50%” to the statement. Background updated. Annual review of policy. Minor wording changes to match language in other pain injection policies. References reviewed and updated, with two additional references added. Specialty review completed. Reworded II. for clarity. Added New 2020 CPT code- 64625 as not medically necessary. Added criteria stating SIJ nerve blocks as not medically necessary, along with code 64451. Revision Date 08/18 Approval Date 08/18 08/19 08/19 01/20 02/20 Page 4 of 8 CLINICAL POLICY Sacroiliac Joint Interventions Reviews, Revisions, and Approvals Added Patrick’s test/FABER test as an acceptable pain provocation test in I.A3. References reviewed and updated. Updated I.A. to specify that the criteria applies to therapeutic injections as well as diagnostic. Updated I.B. to state “A second diagnostic or confirmatory sacroiliac joint injection when pain was improved by at least 75% after the first diagnostic SIJ injection”, rather than that pain did not improve. I.C. updated to specify “therapeutic” SIJ injection. II was changed from 50% to 75%. Updated background. Replaced member with member/enrollee in all instances. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” Annual review completed. References reviewed, updated, and reformatted. Annual review completed. Background updated with no impact to criteria. References reviewed and updated. Specialist reviewed. Revision Date 07/20 Approval Date 08/20 06/21 06/21 08/21 08/21 08/22 08/22