Back Pain: Sacroiliac and Coccydynia Treatment Medical Policy

Service: Back Pain: Sacroiliac and Coccydynia Treatment

PUM 250-0024-1706

Medical Policy Committee Approval 05/27/2021 Effective Date 06/01/2021 Prior Authorization Needed Yes

Related Medical Policies:

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

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/coccodynia, 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 5) 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., 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). The nerve root tension test (straight leg raise), if performed, must be negative unless the provider documents coexistence of both radicular and non-radicular pain. If bilateral injections are requested, the symptoms and physical exam findings, must be bilateral.

3. 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.

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4. Within the last six 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.

Note: If the symptoms are severe (requiring urgent medical care), the trial of conservative treatments (number 3 and/or 4) may not be required.

5. Documentation of an average pain level of 6 or greater on a scale of 0 to 10, or intermittent/continuous pain that is causing a functional disability.

If the above Indications of Coverage (section A, 1 through 5) 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 through 3 below) are met:

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

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

3. The individual has attempted physical therapy (PT), chiropractic treatment, or a home exercise program to increase range of motion and core strength since receiving the previous injection.

Note: The requirement for physical therapy or chiropractic manipulation may be waived if the member received relief for at least 3 months from a prior sacroiliac injection that was given within the past 12 months for the same specific condition.

Sacroiliac Joint Injection Limit: If a limit is not specified in the member health plan, a maximum of four (4) sacroiliac joint injections in a year* (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. Note that bilateral injections will count as 2 injections.

*If a year is not described in the member health plan (e.g. per calendar year), 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:

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

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

3. 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.

4. 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 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.

Note: If the symptoms are severe (requiring urgent medical care), the trial of conservative treatments (numbers 3, 4, and 5 above) may not be required.

If the above Indications of Coverage (letter B, 1through 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: If a limit is not specified in the member health plan, a maximum of two (2) coccyx injections in a year* is considered medically necessary when criteria is met for each injection.

*If a year is not described in the member health plan (e.g. per calendar year), 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:

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

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

3. For treatment of severe trauma (e.g. pelvic ring fracture)

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4. During surgical procedures such as correction of scoliosis extending to the ileum or when performed as part of a multisegmental fusion

D. Percutaneous Minimally Invasive Sacroiliac Joint Fusion (Arthrodesis) procedures using an FDA-approved implant (iFuse), 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 six consecutive months of conservative treatment (e.g., activity modification, bracing, medication, and Physical Therapy) within the past year.

3. Imaging studies exclude the presence of other causes for SIJ dysfunction/pain, including but not limited to: • Acute 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:

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 denied as experimental, investigational, and unproven to affect health outcomes.

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

E. A second coccyx injection provided less than one (1) month after the initial injection will be denied as not medically necessary.

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

G. 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 one year will be denied as not medically necessary. Note that bilateral injections count as 2 injections.

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

I. 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 denied as experimental, investigational, and unproven to affect health outcomes.

J. Sacroiliac joint ablation (includes water cooled, pulsed, and 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 and will be denied.

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

L. Percutaneous sacroplasty will be denied as experimental, investigational, and unproven to affect health outcomes.

M. 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 denied as not medically necessary.

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

Documentation Required:

• History and physical

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• Office visit notes • Relevant reports of prior procedures

Disclaimer: This policy 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 policy. 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 policy in all their coverage determinations. Contact customer services as listed on the member card for specific plan, benefit, and network status information.

Medical policies 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 policy 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 [email protected].

Policy Review History:

Implemented 08/21/17, 10/01/18, 10/01/19, 09/01/2020, 03/01/2021, 06/01/2021 Medical Policy 09/12/14, 09/11/15, PUM 250-0024 retired 06/03/16 effective Committee 09/30/16 to Radiofrequency Ablation, Facet Joint Injection, and Approval others. Coccydynia Injections retired to Back Pain Procedures – Epidural Injections. Policy reinstated 06/16/17 as PUM 250-0024- 1706, 06/15/18, 05/31/19, 05/28/2020, 02/25/2021, 05/27/2021 Reviewed 09/12/14, 09/11/15, 06/03/16, 06/16/17, 06/15/18, 05/31/19, 05/28/2020, 05/27/2021

Approved by the Medical Director

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