DESCRIPTION
Sacroiliac joint arthrography and steroid injection has been explored as a treatment for low back pain. The steroid medication is 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.
POLICY
Arthrography of the sacroiliac joint is considered investigational.
Injection into the sacroiliac joint for diagnostic or therapeutic purposes is considered investigational.
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is reference in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member’s health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
ADDITIONAL INFORMATION
There is limited evidence regarding sacroiliac joint arthrography or injection therapy. These have not been adequately evaluated and evidence is insufficient to permit conclusions regarding the effect of this procedure on health outcomes.
SOURCES
American College of Occupational and Environmental Medicine. (2007). Low back disorders. Occupational medicine practice guidelines: Evaluation and management of common health problems and functional recovery in workers. Retrieved July 8, 2011 from http://www.guideline.gov/popups/printView.aspx?id=12540.
American Society of Anesthesiologists Task Force on Chronic Pain Management. American Society of Regional Anesthesia and Pain Medicine. (2010, April). 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. Retrieved July 8, 2011 from http://www.guideline.gov/popups/printView.aspx?id=23845.
BlueCross BlueShield Association. Medical Policy Reference Manual. (2:2011). Sacroiliac joint arthrography and injection (6.01.23). Retrieved July 8, 2011 from BlueWeb. (18 articles and/or guidelines reviewed)
Institute for Clinical Systems Improvement (ICSI). (2009, November). Assessment and management of chronic pain. Retrieved July 8, 2011 from http://www.guideline.gov/popups/printView.aspx?id=15525.
Manchikanti, L., Boswell, M. V., Singh, V., Benyamin, R. M., Fellows, B., Abdi, S., et al. (2009). Comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician, 12 (4), 699-802. (Level 5 evidence)
Wisconsin Physicians Service Insurance Corporation. (2011, February).Local coverage determination (LCD): Sacroiliac joint injections (L31359). Retrieved July 8, 2011 from http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDid=31359.
ORIGINAL EFFECTIVE DATE: 8/1/2002
MOST RECENT REVIEW DATE: 12/10/2011
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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