Sacroiliac Joint Injections Product Applicability

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Medical Policy

Sacroiliac Joint Injections

Policy Number: OCA 3.9642 Version Number: 15 Version Effective Date: 05/01/17

Product Applicability All Plan+ Products

Well Sense Health Plan Boston Medical Center HealthNet Plan New Hampshire Medicaid MassHealth NH Health Protection Program Qualified Health Plans/ConnectorCare/Employer Choice Direct Senior Care Options ◊

Notes: + Disclaimer and audit information is located at the end of this document. ◊ The guidelines included in this Plan policy are applicable to members enrolled in Senior Care Options only if there are no criteria established for the specified service in a Centers for Medicare & Medicaid Services (CMS) national coverage determination (NCD) or local coverage determination (LCD) on the date of the prior authorization request. Review the member’s product-specific benefit documents at www.SeniorsGetMore.org to determine coverage guidelines for Senior Care Options.

Policy Summary The Plan considers diagnostic or therapeutic sacroiliac joint (SIJ) injections to be medically necessary when performed under fluoroscopic guidance for the management of chronic low back pain. Chronic sacroiliac joint pain is defined as pain that has lasted longer than three (3) months despite appropriate non-surgical intervention such as non-steroidal anti-inflammatory medications and physical therapy. Sacroiliac joint injection for the treatment of acute back pain is not considered medically necessary.

Plan prior authorization is required for diagnostic and/or therapeutic SIJ injections. It will be determined during the Plan’s prior authorization process if the service is considered medically necessary for the requested indication. See the Plan policy, Medically Necessary (policy number OCA Sacroiliac Join Injections

+ Plan refers to Boston Medical Center Health Plan, Inc. and its affiliates and subsidiaries offering health coverage plans to enrolled members. The Plan operates in Massachusetts under the trade name Boston Medical Center HealthNet Plan and in other states under the trade name Well Sense Health Plan. 1 of 22

3.14), for the product-specific definitions of medically necessary treatment. Review Plan policy, Facet Joint Nerve Injections (policy number OCA 3.9641), rather than this policy for guidelines related to facet joint nerve injections. See Plan policy, Denervation of Facet Joints or Sacroiliac Joints, policy number OCA 3.70, rather than this policy for guidelines for denervation of facet joints or sacroiliac joints.

Description of Item or Service Sacroiliac Joint Injection: A diagnostic or therapeutic injection using a local anesthetic agent and/or steroid injected into the sacroiliac joint (i.e., the junction between the sacrum and the ilium that connects the spine to the pelvis) for the treatment of chronic low back pain associated with the sacroiliac joint.

Medical Policy Statement Diagnostic or therapeutic sacroiliac joint (SIJ) injections are considered medically necessary when ALL of the following applicable medical criteria and injection frequency guidelines are met. See item A1 (Criteria for Diagnostic SIJ Injections) and item B1 (Guidelines for Frequency and Number of Injections/Diagnostic Phase) for applicable criteria for diagnostic SIJ injections. Review item A2 (Criteria for Therapeutic SIJ Injections) and item B2 (Guidelines for Frequency and Number of Injections/Treatment or Therapeutic Phase) for applicable criteria for therapeutic SIJ injections.

A. Medical Criteria – Diagnostic or Therapeutic Injections:

SIJ injections may be diagnostic or therapeutic. See applicable criteria below, EITHER item 1 for criteria for diagnostic SIJ injections (including the INITIAL SIJ injection[s] administered by the treating provider on the first day of service when the provider does not differentiate between the diagnostic phase and the therapeutic phase) or item 2 for criteria for therapeutic SIJ injections (or SIJ injections when the treating provider has not conducted a diagnostic phase or does not differentiate between the diagnostic phase and therapeutic phase, but would EXCLUDE the initial SIJ injection[s] administered by the treating provider on the first date of service).

1. Criteria for Diagnostic SIJ Injections:

ALL of the following applicable Plan guidelines for diagnostic* SIJ injections must be met for the treatment to be considered medically necessary, as specified below in items a through f:

a. The member has experienced severe, non-radicular low back pain with BOTH of the following pain characteristics, as specified below in items (1) and (2):

(1) Pain has occurred for at least three (3) months (i.e., chronic pain); AND

(2) Pain is at least intermittent or continuous and is causing functional disability; AND

Sacroiliac Join Injections

b. The member’s low back pain is thought to be secondary to SIJ disturbance based on clinical history and physical exam, and the sacroiliac physical exam includes positive results from at least THREE (3) of the following clinical tests documented in the medical record, as specified below in items (1) through (16):

(1) Compression test;

(2) Fortin finger test;

(3) Gaenslen test;

(4) Gillet’s test (one legged-stork test);

(5) Patrick test (or Faber maneuver);

(6) Piedallu seated flexion test;

(7) Van Durson standing flexion test;

(8) Cranial shear test;

(9) Extension test;

(10) Flamingo test;

(11) Pelvic compression test;

(12) Pelvic distraction test;

(13) Pelvic rock test;

(14) Sacroiliac resisted abduction test (REAB);

(15) Sacroiliac shear test;

(16) Thigh thrust test (POSH); AND

c. The member’s symptoms have failed to respond to conservative treatment (including physical therapy), as defined below in BOTH item (1) and item (2):

(1) Conservative Treatment (Except Physical Therapy):

Sacroiliac Join Injections

The member’s symptoms have failed to respond to at least a three (3)-month course of documented conservative measures, including at least ONE (1) of the following, as specified below in items (a) through (d):

(a) Activity modification; OR

(b) Correction of postural abnormalities; OR

(d) The treating physician, and/or treating licensed independent practitioner practicing within the scope of the practitioner’s license (i.e., nurse practitioner or physician assistant)has documented the member’s inability to undergo or tolerate the conservative treatment specified above in items (a) through (c), with member-specific information to support this determination; AND

(2) Physical Therapy:

ONE (1) of the following criteria is met for physical therapy, as specified below in item (a) for failed clinical response to physical therapy or item (b) when the member is unable to tolerate physical therapy:

(a) Failed Clinical Response to Physical Therapy:

Within the last 24 calendar months of the prior authorization request, the treating physical therapist has documented BOTH of the following conditions in the member’s medical record, as specified below in item i and item ii:

i. The member’s symptoms have failed to respond to six (6) weeks of physical therapy for the member’s condition (i.e., chronic back pain), with member- specific information to support this determination;ⱡ AND

ⱡ Note: The six (6) weeks of physical therapy may also be included as a component of the three (3)-month course of required conservative treatment specified above.

ii. No reduction in associated pain or only a minor reduction in pain with physical therapy, with member-specific information to support this determination; OR

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(b) Inability to Tolerate Physical Therapy:

The treating physical therapist, treating physician, and/or treating licensed independent practitioner practicing within the scope of the practitioner’s license (i.e., nurse practitioner or physician assistant) has documented in the member’s medical record within the last 24 calendar months the member’s inability to physically tolerate physical therapy for this condition (including documentation of the member’s pain levels, member’s functional limitations due to the pain, member’s physical exam findings, and provider’s description of why the member was unable to tolerate physical therapy); AND

d. The SIJ injection is performed under fluoroscopic guidance; AND

e. The member is age 18 or older on the date of service; AND

f. The number of injections does not exceed the Plan’s frequency guidelines specified in item B1 of this section (Guidelines for Frequency and Number of Injections/Diagnostic Phase*); OR

* Note: Plan criteria for diagnostic SIJ injections also apply to the INITIAL SIJ injection(s) administered by the treating provider on the first day of service when the provider does not differentiate between the diagnostic phase and the therapeutic phase.

2. Criteria for Therapeutic SIJ Injections:

ALL of the following applicable Plan guidelines for therapeutic** SIJ injections must be met for the treatment to be considered medically necessary, as specified below in items a through d:

a. ALL criteria must be met for diagnostic* SIJ injections, as specified in item A1 above; AND

b. A previous diagnostic* SIJ injection identifies SIJ disturbance as the source of pain with BOTH of the following results, as specified below in items (1) and (2):

(1) Greater than 70% pain relief from baseline pain after the diagnostic* injection; AND

(2) Demonstrate objective functional improvement without deterioration of pain relief; AND

c. The therapeutic** SIJ injection is provided as part of a comprehensive pain management program, and the pain management program includes ALL of the following components, as specified below in items (1) through (4):

Sacroiliac Join Injections

(1) An individualized treatment plan has been developed for the member by the treating provider; AND

(2) As part of the treatment plan, the treating provider reviews previous and current services and documents in the medical record a physical exam (when appropriate); AND

(3) The treating provider evaluates the results of each SIJ injection and documents the member’s pain condition, duration of clinical response, and functional improvement in activities, including at least ONE (1) of the following, as specified below in items (a) through (e):

(a) Increased social activities; OR

(b) Decreased need for pain medication; OR

(d) Returning to work; OR

(e) Sleeping; AND

(4) The treating provider coordinates a medically necessary service or treatment (as defined in the Plan’s Medically Necessary policy, policy number OCA 3.14) to maximize physical functioning for the member, while complying with the Plan’s prior authorization guidelines; AND

d. The number of injections does not exceed the Plan’s frequency guidelines specified in item B2 of this section (Guidelines for Frequency and Number of Injections/Treatment or Therapeutic Phase); OR

Notes: * Plan criteria for diagnostic SIJ injections also apply to the INITIAL SIJ injection(s) administered by the treating provider on the first day of service when the provider does not differentiate between the diagnostic phase and the therapeutic phase. ** Plan criteria for therapeutic SIJ injections also apply to SIJ injection(s) when the treating provider has not conducted a diagnostic phase or does not differentiate between the diagnostic phase and therapeutic phase (but would EXCLUDE the initial SIJ injection[s] administered by the treating provider on the first date of service).

Sacroiliac Join Injections

B. Guidelines for Frequency and Number of Injections – Diagnostic or Therapeutic Injections:

See applicable criteria below for frequency and number of injections, EITHER item 1 for the diagnostic* phase or item 2 for the treatment or therapeutic** phase. When the Plan’s applicable medical criteria are met (as stated above for either the diagnostic* or therapeutic** phase of treatment), the frequency and number of SIJ injections that are considered medically necessary are as follows:

1. Diagnostic Phase:

ALL of the following criteria must be met for the diagnostic* phase, as specified below in items a through d:

a. Applicable criteria are met for diagnostic* SIJ injections, as specified above in item A1 (Criteria for Diagnostic SIJ Injection); AND

b. Diagnostic* SIJ injections are performed at least one (1) week apart with no more than two (2) injections allowed in a 14-day period (i.e., each series of injections within this guideline counts as one [1] session◊ of treatment for the member); AND

c. No more than one (1) injection is given per side per session◊ (and bilateral injections will be approved by the Plan in the same session◊ when all applicable criteria are met); AND

d. The member has received no more than four (4) sessions◊ of injections (including all SIJ injections administered to the member, including the diagnostic* phase and the therapeutic** phase) in a 12-month period (with the 12-month timeframe beginning on the date of the first injection); AND

2. Treatment or Therapeutic Phase:

ALL of the following applicable criteria must be met for the therapeutic** phase, as specified below in items a through e:

a. Applicable criteria are met for therapeutic** SIJ injections phase, as specified above in item A2 (Criteria for Therapeutic SIJ Injection); AND

b. If the diagnostic* phase was conducted and completed, applicable criteria were met for the diagnostic* phase included in BOTH item A1 (Criteria for Diagnostic SIJ Injection) and item B1 (Guidelines for Frequency and Number of Injections/Diagnostic Phase); AND

c. A previous diagnostic* SIJ injection identifies sacroiliac joint disturbance as the source of pain with BOTH of the following results, as specified below in items (1) and (2):

Sacroiliac Join Injections

(1) Greater than 70% pain relief from baseline pain from the last diagnostic* SIJ injection; AND

(2) Ability to perform previously painful movement without deterioration of pain relief; AND

d. A maximum of four (4) sessions◊ for SIJ injections (including all SIJ injections administered to the member, including the diagnostic* phase and therapeutic** phase) is allowed in a 12-month period and must also comply with ALL of the following parameters, as specified below in items (1) through (3):

(1) It has also been at least two (2) months or longer between injections (i.e., each session◊ of treatment); AND

(2) No more than one (1) injection is given per side per session◊ (i.e., bilateral injections will be approved by the Plan in the same session◊ when all applicable criteria are met); AND

(2) The 12-month timeframe begins on the date of the first injection; AND

e. For a repeat therapeutic** SIJ injection, the previous SIJ injection has provided greater than 50% pain relief from baseline pain for at least six (6) weeks.

Limitations

1. Sacroiliac joint injection for the treatment of acute back pain is not considered medically necessary.

2. Sacroiliac joint injection is considered experimental and investigational for any indication other than chronic low back pain or when Plan criteria are not met. Sacroiliac Join Injections

3. A request for a sacroiliac joint injection for member less than age 18 on the date of service requires Plan Medical Director review.

4. A request for a sacroiliac joint injection for a member with a malignancy at the injection site requires Plan Medical Director review; sacroiliac joint injections may or may not be considered medically necessary after individual consideration (based on clinical documentation provided to the Plan) for palliative pain relief when the member is actively being treated by an oncologist.

5. When the member has exceeded the maximum allowable number of injections specified in the Medical Policy Statement section of this Plan policy, the service is not considered medically necessary.

6. A sacroiliac joint injection conducted without fluoroscopic guided imaging (i.e., blinded) is considered experimental and investigational. A sacroiliac joint injection guided by CT, ultrasonography, or MRI (rather than fluoroscopic guidance) is considered experimental and investigational.

7. A sacroiliac joint injection is not considered medically necessary if a facet injection or epidural is performed at the same session.

8. Contraindications to sacroiliac joint injections include ANY of the following, as specified below in items a through f:

a. Patient with systemic infection or a local infection near the injection site (due to the risk of spreading the infection); OR

b. Patient with an unstable medical condition; OR

c. Patient with a history of significant allergic reaction to the injected solution (which is more prevalent in a multi-use container when a preservative is used); OR

d. Patient is pregnant; OR

e. Patient with a coagulation disorder (coagulopathy); OR

f. Patient with a malignancy at the injection site.

Review Plan policy, Denervation of Facet Joints or Sacroiliac Joints, policy number OCA 3.70, rather than this policy for guidelines for denervation of facet joints or sacroiliac joints. See Plan policy, Experimental and Investigational Treatment (policy number OCA 3.12), for the product-specific definitions of experimental or investigational treatment. Refer to Plan policy, Medically Necessary (policy number OCA 3.14), for the product-specific definitions of medically necessary treatment. Sacroiliac Join Injections

Definitions Compression Test: In the compression test, the patient lies on one side. The examiner applies pressure on one pelvic brim in the direction of the other. A positive result is pain across the sacroiliac (SI) joint.

Flamingo Test: Patient stands on the test extremity lifting the unaffected leg off the ground. Test is positive if patient’s symptoms are reproduced on that side or at the pubic symphysis. An additional provocation may be to add gentle to moderate hopping.

Fortin Finger Test: In the Fortin finger test, the patient points to the area of pain with one finger. The result is positive if the site of pain is within 1 cm of the posterior superior iliac spine (PSIS), generally inferomedially.

Gaenslen Test: In the Gaenslen test, the patient is supine. The hip and knee are maximally flexed toward the trunk, and the opposite leg is extended. Pressure is applied to the flexed extremity. The finding is positive if pain is felt across the SI joint. Gaenslen's test is one of the five (5) provocation tests that can be used to detect musculoskeletal abnormalities and primary-chronic inflammation of the lumbar vertebrae and sacroiliac joint. The subsequent tests include the Distraction test, Thigh thrust test, Compression test and the Sacral thrust test.

Gillet’s Test: Gillet’s test is done with the patient in the standing position. The patient stands on one leg while flexing the opposite hip and knee into the chest. Motion of the sacroiliac joint is assessed by placing one thumb under the posterior superior iliac spine on the side of hip flexion, with the other thumb in the midline at the S2 level. Normally, the thumb under the posterior superior iliac spine drops inferiorly and laterally with hip flexion. Restriction is indicated by decreased motion compared to the normal side.

Patrick Test (or Faber Maneuver): The Patrick test or the Faber maneuver is flexion, abduction, and external rotation of the hip. The patient lies supine. The heel of the tested side is placed on the opposite knee. Pressure is put on the flexed knee and the opposite anterior superior iliac spine area. Result is positive for SI dysfunction if pain is elicited in the SI joint area.

Pelvic Compression Test: The patient lies on his side with the affected side up. The examiner places his forearm over the iliac crest and presses downward for approximately 30 seconds. This test is positive if pain occurs.

Pelvic Rock Test: Pressure is applied on the pelvis while the examiner’s palms are on the iliac tubercles and the thumbs on the anterosuperior iliac spines. Pain at the sacroiliac joint may indicate sacroiliac joint pathology.

Sacroiliac Join Injections

Piedallu Seated Flexion Test: In the Piedallu seated flexion test, the patient is seated with the examiner behind him. The examiner’s thumbs are placed just below the posterior superior iliac spine. The patient flexes the trunk forward. A positive result is asymmetry of motion.

Sacroiliac Resisted Abduction Test (REAB): This test is done with the patient lying on the side with the upper leg straight out and slightly abducted while the lower leg is flexed at the hip and knee for stability. With the patient resisting, the examiner applies downward pressure on the upper limb. The test is then repeated on the opposite side. If this action causes pelvic pain around the posterior superior iliac spine, the test is considered positive, indicating a Sacroiliac lesion, and more specifically, a sacroiliac sprain or subluxation.

Van Durson Standing Flexion Test: In the Van Durson standing flexion test, the patient is standing with the examiner behind him. The examiner’s thumbs are placed just below each posterior iliac spine. The patient flexes the trunk forward without bending the knees. A positive sign is asymmetric motion.

Applicable Coding The Plan uses and adopts up-to-date Current Procedural Terminology (CPT) codes from the American Medical Association (AMA), International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) diagnosis codes developed by the World Health Organization and adapted in the United Stated by the National Center for Health Statistics (NCHS) of the Centers for Disease Control under the U.S. Department of Health and Human Services, and the Health Care Common Procedure Coding System (HCPCS) established and maintained by the Centers for Medicare & Medicaid Services (CMS). Because the AMA, NCHS, and CMS may update codes more frequently or at different intervals than Plan policy updates, the list of applicable codes included in this Plan policy is for informational purposes only, may not be all inclusive, and is subject to change without prior notification. Whether a code is listed in the Applicable Coding section of this Plan policy does not constitute or imply member coverage or provider reimbursement. Providers are responsible for reporting all services using the most up-to-date industry-standard procedure and diagnosis codes as published by the AMA, NCHS, and CMS at the time of the service.

Providers are responsible for obtaining prior authorization for the services specified in the Medical Policy Statement section and Limitation section of this Plan policy, even if an applicable code appropriately describing the service that is the subject of this Plan policy is not included in the Applicable Coding section of this Plan policy. Coverage for services is subject to benefit eligibility under the member’s benefit plan. Please refer to the member’s benefits document in effect at the time of the service to determine coverage or non-coverage as it applies to an individual member. See Plan reimbursement policies for Plan billing guidelines.

Sacroiliac Join Injections

CPT Codes Description: Codes Covered When Medically Necessary (Using Fluoroscopy or CT) 27096 Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed

Plan notes: This code should only be used for the professional component of the service. Code 27096 is a unilateral procedure; for bilateral procedure, use modifier 50. HCPCS Code Description: Codes Covered When Medically Necessary G0260 Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography

Plan note: This code should only be used for the technical component of the service.

Clinical Background Information Lumbar intervertebral discs, facet joints, sacroiliac joint, ligaments, fascia, muscles, and nerve root dura have been shown to be capable of transmitting pain in the lumbar spine with resulting symptoms of low back pain and lower extremity pain. The diagnostic blocks applied in the precision diagnosis of chronic low back pain include lumbar facet joint nerve blocks, lumbar provocation discography, and sacroiliac joint blocks. Noninvasive methods for treating chronic low back pain related to SIJ dysfunction include rest, ice, muscle relaxants, nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy (PT), manual therapy, exercise or activity modification, bracing (sacroiliac belt), chiropractic adjustments, or combinations of these modalities; SIJ injections are used to treat SIJ pain that is refractory to these noninvasive therapies.

Disorders of the sacroiliac joints (SIJ) often contribute to chronic low back pain. By blocking the nerve to the SIJ, the pain impulses can be interrupted. Generally, SIJ injections are performed as part of a work-up for chronic back pain and are considered diagnostic or therapeutic. Diagnostic SIJ injections use short-acting local anesthetics to diagnose SIJ dysfunction as the cause of chronic low back pain. Confirmation that the SIJ is the source of pain is obtained if the block is successful in pain relief. Therapeutic SIJ blocks use long-acting local anesthetics and/or anti-inflammatory agents such as corticosteroids as a treatment for chronic low back pain. If successful, a series of SIJ blocks may be medically necessary for relapse in pain, however, it is generally not reasonable to perform more than 4 series of injections in a 12-month period.

SIJ procedures involve placing a needle into the SIJ, generally under fluoroscopic guidance. Typically, the procedure is done in the outpatient setting and is usually performed by an orthopedic surgeon, physiatrist, interventional radiologist, neurosurgeon, pain management physician, anesthesiologists, or other qualified physician. Serious side effects are rare, but reported complications include local anesthetic reactions, superficial infections, and/or degenerative changes in the joints. Contraindications to SIJ injections with corticosteroids for treatment of chronic low back pain include suspected infection of the joint space or overlying tissue, coagulopathy, pregnancy, allergy to

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components of the injection, fusion of the joint space so that a needle cannot be inserted, and suspected psychogenic pain.

At the time of the Plan’s most recent policy review, no national coverage determination (NCD) or local coverage determination (LCD) was found for sacroiliac joint injections from the Centers for Medicare & Medicaid Services (CMS). LCD L35936 includes guidelines for facet joint injections, medial branch blocks, and facet joint radiofrequency neurotomy. Determine if applicable CMS criteria are in effect for this service in an NCD or LCD on the date of the prior authorization request for a Senior Care Options member.

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American Society of Anesthesiologists (ASA) and American Society of Regional Anesthesia and Pain Medicine (ASRA). Practice Guidelines for Chronic Pain Management: an Updated Report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology. 2010;112(4):810-833.

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American Society of Interventional Pain Physicians (ASIPP). Boswell MV, Shah RV, Everett CR, Sehgal N, McKenzie Brown AM, Abdi S, Bowman RC, Deer TR, Datta S, Colson JD, Spillane WF, Smith HS, Lucas LF, Burton AW, Chopra P. Staats PS, Wasserman RA, Manchikanti L. Interventional Techniques in the Management of Chronic Spinal Pain: Evidence-Based Practice Guidelines. Pain Physician. 2005;8(1):1- 47. Accessed at: http://www.ncbi.nlm.nih.gov/pubmed/16850041 or http://asipp.org/documents/Jan05journal.pdf

American Society of Interventional Pain Physicians (ASIPP). IPM Guidelines. An Update of Comprehensive Evidence-Based Guidelines for Interventional Techniques in Chronic Spinal Pain. Part 1: Introduction and General Considerations. Pain Physician 2013; 16:S1-S48. ISSN 1533-3159.

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Bodguk N et al. A narrative review of lumbar medial branch neurotomy for the treatment of back pain. Pain Med. 2009 Sep;10(6):1035-45.

Borowsky CD et al. Sources of Sacroiliac Region Pain: Insights Gained From a Study Comparing Standard Intra-Articular Injection With a Technique Combining Intra- and Peri-Articular Injection. Arch Phys Med Rehab. 2008, Nov;89:2048-2056.

Boswell MV et al. Interventional Techniques: Evidence-based Practice Guidelines in the Management of Chronic Spinal Pain. Pain Physician. 2007; 10:7-111.

Boswell MV et al. Therapeutic Facet Joint Interventions in Chronic Spinal Pain: A Systematic Review of Effectiveness and Complications. Pain Physician. 2005; 8:101-114.

Braun J and Sieper J. The sacroiliac joint in the spondyloarthropathies. Curr Opin Rheumatol. 1996 Jul;8(4):275-87. Accessed at: http://www.gentili.net/frame2.asp?ID=478&URL=9891707

Buker N, Akkaya S, Gokalp O, Kitis A, Savkin R, Kiter AE. Middle-term therapeutic effect of the sacroiliac joint blockade in patients with lumbosacral fusion-related sacroiliac pain. Acta Orthop Traumatol Turc. 2014;48(1):61-66.

Burgos-Vargas R. The assessment of the spondyloarthritis international society concept and criteria for the classification of axial spondyloarthritis and peripheral spondyloarthritis: A critical appraisal for the pediatric rheumatologist. Pediatr Rheumatol Online J. 2012; 10: 14. Published online 2012 May 31. doi: 10.1186/1546-0096-10-14. PMCID: PMC3403902.

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Centers for Medicare and Medicaid Services (CMS). Local Coverage Determination (LCD). Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy (L35936). National Government Services, Inc. Accessed at: https://www.cms.gov/medicare-coverage- database/search/search- results.aspx?CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All&KeyWord=facet+joint+ injection&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAAAAAAAAAAA%3D%3D&=&

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Cohen SP et al. Sacroiliac Joint Pain: A Comprehensive Review of Anatomy, Diagnosis, and Treatment. Anesth Analg. 2005;101:1440 –53. Accessed at: http://www.anesthesia- analgesia.org/cgi/reprint/101/5/1440.pdf

Cook KM, Heiderscheit B. Conservative management of a young adult with hip arthrosis. J Orthop Sports Phys Ther. 2009 Dec;39(12):858-66.

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Davis PC et al. Expert Panel on Neurologic Imaging. ACR Appropriateness Criteria® low back pain. [online publication]. Reston (VA): American College of Radiology (ACR); 2008. Updated 2011. Accessed at: http://guideline.gov/content.aspx?id=35145

Dreyfuss P et al. The ability of single site, single depth sacral lateral branch blocks to anesthetize the sacroiliac joint complex. Pain Med. 2008 Oct;9(7):844-50.

Forst SL, Wheeler MT, Fortin JD, Vilensky JA. The sacroiliac joint: anatomy, physiology and clinical significance. Pain Physician. 2006 Jan;9(1):61-7.

Gunaydin I et al. Magnetic resonance imaging guided corticosteroid injection of sacroiliac joints in patients with spondylarthropathy. Are multiple injections more beneficial? Rheumatol Int. 2006 Mar;26(5):396-400.

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Hansen HC, McKenzie-Brown AM, Cohen SP, Swicegood JR, Colson JD, Manchikanti L. Sacroiliac joint interventions: a systematic review. Pain Physician. 2007;10(1):165-184.

Sacroiliac Join Injections

Hayes Health Technology Brief. Sacroiliac Joint Injections with Corticosteroids for Treatment of Chronic Low Back Pain. Winifred Hayes, Inc. December 22, 2016.

Hee Do K, Ho Ahn S, Jones R, Ho Jang S, Min Son S, Gyu Lee D, Kyuong Cho H, Sik Choi G, Cho YW. A New Sacroiliac Joint Injection Technique and Its Short-Term Effect on Chronic Sacroiliac Region Pain. Pain Med. 2016 Feb 25. pii: pnw003. PMID: 26917623. DOI: 10.1093/pm/pnw003. Accessed at: https://www.ncbi.nlm.nih.gov/pubmed/26917623

Jee H, Lee JH, Park KD, Ahn J, Park Y. Ultrasound-guided versus fluoroscopy-guided sacroiliac joint intra-articular injections in the noninflammatory sacroiliac joint dysfunction: A prospective, randomized, single-blinded study. Arch Phys Med Rehabil. 2014 Feb;95(2):330-7. doi: 10.1016/j.apmr.2013.09.021. Epub 2013 Oct 9. PMID: 24121083. Accessed at: https://www.ncbi.nlm.nih.gov/pubmed/24121083

Kennedy DJ, Shokat M, Visco CJ. Sacroiliac joint and lumbar zygapophysial joint corticosteroid injections. Phys Med Rehabil Clin N Am. 2010 Nov;21(4):835-42.

Kishner S et al. Medscape Reference. Sacroiliac Injection. Updated March 7, 2013. Accessed at: http://emedicine.medscape.com/article/103399-overview

Kotsenas AL. Imaging of posterior element axial pain generators: facet joints, pedicles, spinous processes, sacroiliac joints, and transitional segments. Radiol Clin North Am - 01-Jul-2012; 50(4): 705- 30.

Krawczyk-Wasielewska A, Skorupska E, and Samborski W. Sacroiliac joint pain as an important element of psoriatic arthritis diagnosis. Postepy Dermatol Alergol. 2013 Apr; 30(2): 108112. Published online 2013 Apr 12. doi: 10.5114/pdia.2013.34161 PMCID: PMC3834688. Accessed at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3834688/

Laslett M. Evidence-Based Diagnosis and Treatment of the Painful Sacroiliac Joint. J Man Manip Ther. 2008; 16(3): 142152. PMCID: PMC2582421. Accessed at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2582421/

Malfair D. Therapeutic and diagnostic joint injections. Radiol Clin North Am - 01-MAY-2008; 46(3): 439- 53.

Sacroiliac Join Injections

Manchikanti L, Abdi S, Atluri S, Benyamin RM, Boswell MV, Buenaventura RM, Bryce DA, Burks PA, Caraway DL, Calodney AK, Cash KA, Christo PJ, Cohen SP, Colson J, Conn A, Cordner H, Coubarous S, Datta S, Deer TR, Diwan S, Falco FJ, Fellows B, Geffert S, Grider JS, Gupta S, Hameed H, Hameed M, Hansen H, Helm S 2nd, Janata JW, Justiz R, Kaye AD, Lee M, Manchikanti KN, McManus CD, Onyewu O, Parr AT, Patel VB, Racz GB, Sehgal N, Sharma ML, Simopoulos TT, Singh V, Smith HS, Snook LT, Swicegood JR, Vallejo R, Ward SP, Wargo BW, Zhu J, Hirsch JA. An update of comprehensive evidence- based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain Physician. 2013 Apr;16(2 Suppl):S49-S283. Accessed at: http://www.guideline.gov/content.aspx?id=45379&search=chronic+spinal+pain+2013

Manchikanti L, Boswell MV, Singh V, Benyamin RM, Fellows B, Abdi S, Buenaventura RM, Conn A, Datta S, Derby R, Falco FJE, Erhart S, Diwan S, Hayek SM, Helm S, Parr AT, Schultz DM, Smith HS, Wolfer LR, Hirsch JA. Comprehensive Evidence-Based Guidelines for Interventional Techniques in the Management of Chronic Spinal Pain. Pain Physician 2009; 12:699-802. Accessed at: http://www.guideline.gov/content.aspx?id=45379

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Manchikanti L, Manchikanti KN, Manchukonda R, Cash KA, Damron KS, Pampati V, McManus CD. Evaluation of Lumbar Facet Joint Nerve Blocks in the Management of Chronic Low Back Pain: Preliminary Report of A Randomized, Double-Blind Controlled Trial: Clinical Trial NCT00355914. Pain Physician. 2007; 10:425-440. PMID: 17525777. Accessed at: https://www.ncbi.nlm.nih.gov/pubmed/17525777

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Sacroiliac Join Injections

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Sacroiliac Join Injections

Original Effective Original Approval Date and Version Policy Owner Approved by Date* Number Regulatory Approval: N/A 11/01/08 Medical Policy Manager MPCTAC , Utilization Version 1 as Chair of Medical Policy, Management Committee Internal Approval: Criteria, and Technology (UMC), and QIC 06/10/08: MPCTAC Assessment Committee 06/24/08: UMC (MPCTAC) 08/13/08: QIC and member of Quality Improvement Committee (QIC) *Effective Date for the BMC HealthNet Plan Commercial Product(s): 01/01/12 *Effective Date for the Well Sense Heath Plan New Hampshire Medicaid Product(s): 01/01/13 *Effective Date for the Senior Care Options Product(s): 01/01/16

Effective 06/01/13, this policy replaced the Facet Joint Nerve Injections and Sacroiliac Joint Injections for Chronic Neck Pain and Chronic Back Pain policy (policy number OCA 3.964) which was effective from 11/01/08 to 05/31/13. Also, see Plan policy, Facet Joint Nerve Injections for Chronic Back Pain and Chronic Neck Pain (policy number OCA 3.9641) effective 06/01/13.

Policy Revisions History Revision Review Effective Date Summary of Revisions Approved by Date and Version Number 06/23/09 Changed name of the policy, added additional criteria 10/01/09 06/23/09: MPCTAC for SIJ injections and replaced the criteria for Version 2 06/23/09: UMC radiological findings negative for disc herniation and 07/22/09: QIC nerve root compression with: negative physical signs of radiculopathy or radicular pain, including negative straight leg raising or root tension signs, normal neurological examination, absence of signs of radiculopathy on any electrodiagnostic examinations. Updated the diagnostic clinical criteria to allow no more than 2 joint levels bilaterally or 3 joint levels unilaterally in a 7 to 14 day period to determine the origin of the patient’s pain. For SIJ injections, no more than 2 procedures may be allowed in a 7 to 14 day period to determine the origin of the patient’s pain. Updated references and coding sections. Effective date of changes is 10/01/09. 06/01/10 No changes to criteria. Updated references and Version 3 06/30/10: MPCTAC coding. 07/28/10: QIC 06/01/11 Updated clinical criteria to clarify that the absence of Version 4 06/29/11: MPCTAC prior spinal fusion must be at the clinically suspect 07/27/11: QIC Sacroiliac Join Injections

Policy Revisions History levels. Updated references. 07/01/12 Updated references and revised the introductory Version 5 06/20/12: MPCTAC paragraph in Applicable Coding section. Code 07/18/12: MPCTAC descriptions updated but no change to list of 08/22/12: QIC applicable codes. Revised policy title and text to specify the policy relates to chronic neck pain and

chronic back pain. Added the following additional contraindication for procedures: ‘Patient with a malignancy at the injection site.’ Clinical criteria updated for facet joint nerve injections and sacroiliac joint injections. Definitions added for radiculopathy and straight leg raise test. For facet joint injections, added symptoms of axial pain and signs of facet disease. For sacroiliac joint injections, added types of tests used for a sacroiliac exam. Added definition of a comprehensive pain management program and referenced the Plan’s Medically Necessary policy. 08/01/12 Off cycle review for Well Sense Health Plan. No Version 6 08/13/12: MPCTAC changes. 09/06/12: QIC 12/01/12 Revised sacroiliac joint injection frequency guidelines Version 7 12/19/12: MPCTAC in Medical Policy Statement section. 12/20/12: QIC 02/01/13 Review for effective date 06/01/13. Separated facet 06/01/13 02/20/13: MPCTAC joint nerve injections and sacroiliac joint injections Version 8 03/21/13: QIC into two separate policies; policy formerly titled Facet Joint Nerve Injections and Sacroiliac Joint Injections for Chronic Neck Pain and Chronic Back Pain (formerly policy number OCA 3.964). Revised title and re- numbered policy. Updated language in Summary, Description of Item or Service, and Clinical Background Information sections. Revised applicable code list, and updated references. Deleted definitions for radiculopathy and straight leg raise test in Definition section because not referenced in policy. Added the following definitions: Compression test, Fortin finger test, Gaenslen test, Gillet’s test, Patrick test (or Faber maneuver), Piedallu seated flexion test, and Van Durson standing flexion test. Revised medical criteria in the Medical Policy Statement section (formerly named the Clinical Guideline Statement section). 08/14/13 Off cycle review for Well Sense Health Plan and Version 9 08/14/13: MPCTAC merged policy format. Incorporate policy revisions (electronic vote) dated 12/01/12 and 02/01/13 (as specified above) for 08/15/13: QIC the Well Sense Health Plan product; these policy

Sacroiliac Join Injections

Policy Revisions History revisions were approved by MPCTAC (on 12/19/12 and 02/20/13) and QIC (on 12/20/12 and 03/21/13) for applicable Plan products. 03/01/14 Review for effective date 07/01/14. Changed policy 07/01/14 03/19/14: MPCTAC title from Sacroiliac Joint Injections for Chronic Low Version 10 04/16/14: QIC Back Pain to Sacroiliac Joint Injections. Revised Summary and References sections. Revised criteria in the Medical Policy Statement section and the Limitations section. Removed HCPCS code G0259 as an applicable code. 09/01/14 Review for effective date 11/01/14. Clarified in the 11/01/14 09/17/14: MPCTAC Medical Policy Statement section that bilateral Version 11 10/08/14: QIC injections may be medically necessary for both the diagnostic phase and therapeutic phase when all Plan applicable criteria are met. Updated references. 02/01/15 Review for effective 06/01/15. Updated Definitions 06/01/15 02/27/15: MPCTAC and References sections. Revised criteria in the Version 12 (electronic vote) Medical Policy Statement and Limitations sections. 03/11/15: QIC Removed Commonwealth Care, Commonwealth Choice, and Employer Choice from the list of applicable products because the products are no longer available. 11/25/15 Review for effective date 01/01/16. Updated 01/01/16 11/18/15: MPCTAC template with list of applicable products and notes. Version 13 11/25/15: MPCTAC Revised language in the Applicable Coding section. (electronic vote) 12/09/15: QIC 02/01/16 Review for effective date 06/01/16. Updated criteria 06/01/16 02/17/16: MPCTAC in the Medical Policy Statement section. Version 14 03/09/16: QIC Administrative changes made to the Applicable Coding section without changing the list of codes. Revised the Clinical Background Information, References, and Reference to Applicable Laws and Regulations sections. 01/01/17 Review for effective date 05/01/17. Updated criteria 05/01/17 01/18/17: MPCTAC in the Medical Policy Statement and Limitations Version 15 02/08/17: QIC sections. Updated Summary, Clinical Background Information, and References sections. Plan note added to Applicable Coding section (with no change to the applicable code list).

Last Review Date 01/01/17

Sacroiliac Join Injections

Next Review Date 02/01/18

Authorizing Entity QIC

Other Applicable Policies Medical Policy - Experimental and Investigational Treatment, policy number OCA 3.12 Medical Policy - Denervation of Facet Joints or Sacroiliac Joints, policy number OCA 3.70 Medical Policy - Facet Joint Nerve Injections, policy number OCA 3.9641 Medical Policy - Medically Necessary, policy number OCA 3.14

Reference to Applicable Laws and Regulations 78 FR 48164-69. Centers for Medicare & Medicaid Services (CMS). Medicare Program. Revised Process for Making National Coverage Determinations. August 7, 2013. Accessed at: https://www.cms.gov/Medicare/Coverage/DeterminationProcess/Downloads/FR08072013.pdf

Disclaimer Information: + Medical Policies are the Plan’s guidelines for determining the medical necessity of certain services or supplies for purposes of determining coverage. These Policies may also describe when a service or supply is considered experimental or investigational, or cosmetic. In making coverage decisions, the Plan uses these guidelines and other Plan Policies, as well as the Member’s benefit document, and when appropriate, coordinates with the Member’s health care Providers to consider the individual Member’s health care needs. Plan Policies are developed in accordance with applicable state and federal laws and regulations, and accrediting organization standards (including NCQA). Medical Policies are also developed, as appropriate, with consideration of the medical necessity definitions in various Plan products, review of current literature, consultation with practicing Providers in the Plan’s service area who are medical experts in the particular field, and adherence to FDA and other government agency policies. Applicable state or federal mandates, as well as the Member’s benefit document, take precedence over these guidelines. Policies are reviewed and updated on an annual basis, or more frequently as needed. Treating providers are solely responsible for the medical advice and treatment of Members. The use of this Policy is neither a guarantee of payment nor a final prediction of how a specific claim(s) will be adjudicated. Reimbursement is based on many factors, including member eligibility and benefits on the date of service; medical necessity; utilization management guidelines (when applicable); coordination of benefits; adherence with applicable Plan policies and procedures; clinical coding criteria; claim editing logic; and the applicable Plan – Provider agreement.

Sacroiliac Join Injections