DESCRIPTION
Sacroiliac joint steroid injection for the treatment of low back pain involves a steroid medication being injected into the synovial sac of the sacroiliac joint. The diagnostic objective is to help determine the origin of the low back pain. The therapeutic objective is temporary relief of low back pain unresponsive to conservative treatment (e.g., oral medications, rest/limited activity, and/or physical therapy). Fluoroscopy visualization is used for needle placement. The procedure is performed in the outpatient setting.
The scientific literature does not reveal a consensus of definition for acute and chronic low back pain. The following definitions will be used for the purpose of this policy. It is also recognized that acute exacerbations or new acute episodes may be superimposed on otherwise chronic conditions.
Acute low back pain is pain that is resolved during the expected healing time of a low back injury or illness, usually considered to be 6 months or less.
Chronic low back pain is pain that persist beyond the expected healing time of a low back injury or illness, usually considered to be beyond 6 months
POLICY
Sacroiliac joint steroid injection for the treatment of acute or chronic low back pain is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
MEDICAL APPROPRIATENESS
Sacroiliac joint steroid injection for the treatment of low back pain is considered medically appropriate if ALL of the following criteria are met:
The treatment is performed under fluoroscopy
ANY ONE of the following:
The steroid injection is used as a diagnostic trial to determine the origin of the pain
The steroid injection is used as a therapeutic injection when temporary relief of low back pain is determined to be clinically appropriate (e.g., to participate in physical therapy or essential activities of daily living) and when conservative treatment has failed (e.g., oral medications, rest/limited activity, and/or physical therapy)
ABSENCE of ALL of the following:
Allergy to the medication to be administered
Anticoagulation therapy
Bleeding disorder
Localized infection in the region to be injected
Systemic infection
ADDITIONAL INFORMATION
Some co-morbidities may be exacerbated by the procedure/steroid usage including, but are not limited to:
Poorly controlled hypertension
Severe congestive heart failure
Diabetes
In order to minimize the risks from large doses of steroids, greater than 4 (four) injections within a 12-month period is not generally appropriate.
SOURCES
Aeschbach A., & Mekhail N. (2000). Common nerve blocks in chronic pain management. Anesthesiology Clinics of North America, 18 (2). 429-59.
BioMechanics. (2000), April). Pain Management: Studies probe complexities of sacroiliac joint syndrome. Retrieved September 20, 2005 from http://www.kalindrar.com/studies_probe.pdf.
BlueCross BlueShield Association. Medical Policy Reference Manual. (8:2008). Sacroiliac joint arthrography (6.01.23). Retrieved October 21, 2008 from BlueWeb.
BlueCross BlueShield of Tennessee network physicians. January 2002.
Elgafy, H., Semaan, H. B., Ebraheim, N. A., & Coombs, R. J. (2001). Computed tomography findings in patients with sacroiliac pain. Clinical Orthopaedics and Related Research, 1 (382), 112-118.
National Guideline Clearinghouse. (2007). Interventional Techniques: evidence-based practice guidelines in the management of chronic spinal pain. Retrieved October 21, 2008 from http://www.guideline.gov/summary/summary.aspx?doc_id=10531&nbr=005510&string=evidence-based+AND+practice+AND+guidelines+AND+management+AND+chronic+AND+spinal+AND+pain
Slipman, C. W., Lipetz, J. S., Plastaras, C. T., Jackson, H. B., Vresilovic, E. J., Lenrow, D. A., et al. (2001). Fluoroscopically guided therapeutic sacroiliac injections for sacroiliac joint syndrome. American Journal of Physical Medicine & Rehabilitation, 80 (6), 425-432.
Zelle, B.A., Gruen, G.S., Brown, S., & George, S. (2005) Sacroiliac joint dysfunction: Evaluation and management. The Clinical Journal of Pain, 21 (5), 446-455. Abstract retrieved September 19, 2005 from PubMed database.
ORIGINAL EFFECTIVE DATE: 8/1/2002
MOST RECENT REVIEW DATE: 4/14/2009
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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