BlueCross BlueShield of Tennessee Medical Policy Manual

Diagnosis and Treatment of Sacroiliac Joint Pain

Does not apply to Medicare Advantage

DESCRIPTION

Similar to other structures in the spine, it is assumed that the sacroiliac joint may be a source of low back pain.  Sacroiliac joint pain is typically without any consistent, demonstrable radiographic or laboratory features and most commonly exists in the setting of morphologically normal joints.  Clinical tests for sacroiliac joint pain may include various movement tests, palpation to detect tenderness and description of the pain.  Inconsistent information obtained from history and physical exam and the potential for referred pain from posterior facet joints and lumbar discs make sacroiliac joint dysfunction difficult to diagnose. The use of image-guided anesthetic injection into the sacroiliac joint has been proposed to diagnose sacroiliac joint pain.

Treatment of sacroiliac joint pain with corticosteroids, radiofrequency ablation (e.g., Sinergy®), stabilization or minimally invasive arthrodesis (e.g., iFuse Implant System, iFuse 3D, SI-FIX Sacroiliac Joint Fusion System, SImmetry Sacroiliac Joint Fusion System, and SI-LOK) has also been explored.

POLICY

Policies with similar titles:  Diagnosis and Treatment of Facet Joint Pain

MEDICAL APPROPRIATENESS

IMPORTANT REMINDERS

Does not apply to Medicare Advantage.

ADDITIONAL INFORMATION

There is insufficient evidence to determine the effects of sacroiliac joint arthrography, radiofrequency ablation and arthrodesis of the sacroiliac joint on health outcomes. 

SOURCES 

Agency for Healthcare Research and Quality. (2015). Pain management injection therapies for low back pain. Retrieved April 19, 2016 from https://www.cms.gov/Medicare/Coverage/DeterminationProcess/Downloads/id98TA.pdf.

BlueCross BlueShield Association. Medical Policy Reference Manual. (10:2016). Diagnosis and treatment of sacroiliac joint pain (6.01.23). Retrieved July 5, 2017 from BlueWeb. (35 articles and/or guidelines reviewed)

Dengler, J., Sturesson, B., Kools, D., Prestamburgo, D., Cher, D., van Eeckhoven, E., et al. (2016). Referred leg pain originating from the sacroiliac joint: 6-month outcomes from the prospective randomized controlled iMIA trial. Acta Neurochirurgica, 158 (11), 2219-2224. (Level 2 evidence)

Dengler, J., Duhon, B., Whang, P., Frank, C., Glaser, J., Sturesson, B., et al. (2017). Spine, doi: 10.1097/BRS 2169. [Epub ahead of print]. (Level 2 evidence)

Duhon, B. S., Cher, D. J., Wine, K. D., Kovalsky, D. A., and Lockstadt, H. (2016). Triangular titanium implants for minimally invasive sacroiliac joint fusion: a prospective study. Global Spine Journal, 2016 (6), 257-269.

Duhon, B.S., Bitan, F., Lockstadt, H., Kovalsky, D., Cher, D.,&  Hillen, T. (2016). Triangular titanium implants for minimally invasive sacroiliac joint fusion: 2-year follow-up from a prospective multicenter trial. International Journal of Spine Surgery, 10 (13). DOI: 10.14444/3013. (Level 3 evidence)

Heiney, J., Capobianco, R., & Cher, D. (2015). A systematic review of minimally invasive sacroiliac joint fusion utilizing a lateral transarticular technique. International Journal of Spine Surgery, 9 (40), 1-16. (Level 4 evidence)

Kennedy, D., Engel,A., Kreiner, D., Nampiaparampil, D., Duszynski, B., & MacVicar, J. (2015). Fluoroscopically guided diagnostic and therapeutic intra-articular sacroiliac joint injections: a systematic review. Pain Medicine, 19 (8), 1500-1508. Abstract retrieved April 20, 2016 from PubMed database.

Leggett, L., Soril, L., Lorenzetti, D., Noseworthy, T., Steadman, R., Tiwana, S., & Clement, F. (2014). Radiofrequency ablation for chronic low back pain: a systematic review of randomized controlled trials. Pain and Research Management, 19 (5), e146-e153. (Level 2 evidence)

Lingutla, K., Pollock, R., & Ahuja, S. (2016). Sacroiliac joint fusion for low back pain: a systematic review and meta-analysis. European Spine Journal, 25 (6), 1924-1931. Abstract retrieved July 5, 2017 from PubMed database.

Manchikanti, L., Abdi, S., Atluri, S., Benyamin, R., Boswell, M., Buenaventura, R., et al. (2013). An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: Guidance and recommendations. Pain Physician, 2013 (16), S49-S283. (Level 1 evidence)

Manchikanti, L., Datta, S., Derby, R., Wolfer, L., Benyamin, R., & Hirsch, J. (2010). A critical review of the American pain society clinical practice guidelines for interventional techniques: Part 1. Diagnostic Interventions. Pain Physician, 2010 (13), E141-E174. (Level 2 evidence)

Manchikanti, L., Datta, S., Gupta, S., Munglani, R., Bryce, D., Ward, S., et al. (2010). A critical review of the American pain society clinical practice guidelines for interventional techniques: Part 2. Therapeutic Interventions. Pain Physician, 2010 (13), E215-E264. (Level 2 evidence)

National Institute for Health and Care Excellence. (2017). Minimally invasive sacroiliac joint fusion surgery for chronic sacroiliac pain. Retrieved May 15, 2017 from www.nice.org.uk/guidance/ipg578.

Polly, D., Swofford, J., Whang, P., Frank, C., Glaser, J., Limoni, R., et al. (2016). Two-year outcomes from a randomized controlled trial of minimally invasive sacroiliac joint fusion vs. non-surgical management for sacroiliac joint dysfunction. International Journal of Spine Surgery, 10 (28), 1-22. (Level 2 evidence)

Rudolf, L., and Capobianco, R. (2014). Five-year clinical and radiographic outcomes after minimally invasive sacroiliac joint fusion using triangular implants. The Open Orthopaedics Journal, 2014 (8), 375-383. Retrieved January 9, 2015 from PubMed database. (Level 4 evidence)

Sachs, D., & Capobianco, R. (2012). One year successful outcomes for novel sacroiliac joint arthrodesis system. Annals of Surgical Innovation and Research, 2012, 6:13. (Level 4 evidence)

Simopoulos, T., Manchikanti, L., Gupta, S., Aydin, S., Kim, C.H., Solanki, D., et al. (2015). Systematic review of the diagnostic accuracy and therapeutic effectiveness of sacroiliac joint interventions. Pain Physician, 2015 (18), E713-E756. (Level 1 evidence)

Spain, K., & Holt, T. (2017). Surgical revision after sacroiliac joint fixation or fusion. International Journal of Spine Surgery, 11 (1), 24-30. (Level 4 evidence)

Sturesson, B., Kools, D., Pflugmacher, R., Gasbarrini,A., Prestamburgo, D., & Dengler, J. (2016). Six-month outcomes from a randomized controlled trial of minimally invasive SI joint fusion with triangular titanium implants vs conservative management. European Spine Journal, 2016 May 14 [Epub ahead of print].

U. S. Food and Drug Administration. (2010, August). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K101372. Retrieved May 25, 2012 from http://www.accessdata.fda.gov/cdrh_docs/pdf10/K101372.pdf.

U. S. Food and Drug Administration. (2012, October). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K122074. Retrieved April 4, 2013 from http://www.accessdata.fda.gov/cdrh_docs/pdf12/K122074.pdf.

Vanaclocha, V., Herra, J., Sáiz-Sapena, N., Rivera-Paz, M., & Verdú-Lόpez, F. (2017). Minimally invasive sacroiliac joint fusion, radiofrequency denervation, and conservative management for sacroiliac joint pain: 6-year comparative case series. Neurosurgery, doi: 10.1093/neuros/nyx185. [Epub ahead of print]. (Level 4 evidence)

Winifred S. Hayes, Inc. Medical Technology Directory. (2017). Radiofrequency ablation for sacroiliac joint denervation for chronic low back pain. Retrieved July 5, 2017 from www.Hayesinc.com/subscribers. (57 articles and/or guidelines reviewed)

Wisconsin Physicians Service Insurance Corporation. (2016, February). Percutaneous minimally invasive fusion/stabilization of the sacroiliac joint for the treatment of back pain (L36000). Retrieved April 21, 2016 from https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=36000.

Zaidi, H. A., Montoure, A., J., and Dickman, C. A. (2015). Surgical and clinical efficacy of sacroiliac joint fusion: a systematic review of the literature. Journal of Neurosurgical Spine, 23 (1), 59-66. Abstract retrieved April 25, 2016 from PubMed database.

ORIGINAL EFFECTIVE DATE:  8/1/2002

MOST RECENT REVIEW DATE:  9/7/2017

ID_BA

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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