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, SI-FIX Sacroiliac Joint Fusion System, SImmetry Sacroiliac Joint Fusion System, and SI-LOK) has also been explored.

This policy does not address the treatment of sacroiliac joint pain due to infection or neoplasm.

POLICY

MEDICAL APPROPRIATENESS

IMPORTANT REMINDERS

ADDITIONAL INFORMATION

There is insufficient evidence to determine the effects of arthrography and radiofrequency ablation of the sacroiliac joint on health outcomes.  Evidence is insufficient to determine the effects of SI joint fusion/fixation with a cylindrical threaded implant. Controlled trials and longer follow-up are needed to evaluate this type of implant.

SOURCES

American College of Radiology. (2016). ACR appropriateness criteria® chronic back pain: suspected sacroiliitis/spondyloarthropathy. Retrieved January 2, 2018 from the National Guideline Clearinghouse (NGC: 011034).

BlueCross BlueShield Association. Medical Policy Reference Manual. (12:2017). Diagnosis and treatment of sacroiliac joint pain (6.01.23). Retrieved December 29, 2017 from BlueWeb. (40 articles and/or guidelines reviewed)

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)

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)

Rappoport, L.H., Luna, I.Y., & Joshua, G. (2017). Minimally invasive sacroiliac joint fusion using a novel hydroxyapatite-coated screw: preliminary 1-year clinical and radiographic results of a 2-year prospective study. World Neurosurgery, 101, 493-497. Abstract retrieved December 29, 2017 from PubMed database.

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)

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. Health Technology Brief. (2017). iFuse implant system (SI-Bone Inc.) for sacroiliac joint fusion for treatment of sacroiliac joint dysfunction. Retrieved January 2, 2018 from www.Hayesinc.com/subscribers. (37 articles and/or guidelines reviewed)

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 January 2, 2018 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:  5/7/2018

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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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