Sacroiliac (SI) joint arthrography using fluoroscopic guidance with injection (27096, 77003, G0260) has been explored as a diagnostic test for sacroiliac joint pain or to treat low back pain. Duplication of the patient’s pain pattern with the injection of contrast medium suggests a sacroiliac etiology, as does relief of chronic back pain with injection of local anesthetic.

Sacroiliac joint injection for the treatment of back pain associated with localized SI joint pathology (e.g., inflammatory arthritis, sacroiliitis) confirmed on imaging studies is considered medically necessary.

Arthrography of the sacroiliac joint with injection for diagnostic or therapeutic purposes is considered experimental/investigational, and therefore, non-covered. SI joint injection for the diagnosis or treatment of acute, subacute, or chronic low back pain thought to be SI joint related or radicular pain syndromes is considered experimental/investigational and therefore, non-covered. There is insufficient evidence from peer-reviewed medical literature demonstrating the effectiveness of SI injections in the diagnosis or treatment of back pain or radicular syndromes. A participating, preferred, or network provider can bill the member for the non-covered service.

Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures of the sacroiliac joint reported under procedure code 77003 for conditions other than inflammatory arthritis of the sacroiliac joint or sacroiliitis is considered experimental/investigational, and therefore, non-covered. A participating, preferred, or network provider can bill the member for the non-covered service.

Place of Service: Outpatient

Sacroiliac joint injection is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure under special conditions, including, but not limited to, current therapeutic anticoagulation therapy.

Description

The sacroiliac (SI) joint is the joint in the bony pelvis between the sacrum and the ilium of the pelvis, which are joined together by strong ligaments. The sacrum supports the spine and is supported in turn by an ilium on each side. The joint is a strong, weight bearing synovial joint with irregular elevations and depressions that produce interlocking of the two bones.

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 pain descriptions by the patient. Further confounding the study of the sacroiliac joint is that multiple structures, such as the posterior facet joints and lumbar discs, may refer pain to the area surrounding the sacroiliac joint.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program.

Cohen SP, Hurley RW, Buckenmaier CC 3rd, Kurihara C, Morlando B, Dragovich A. Randomized placebo-controlled study evaluating lateral branch radiofrequency denervation for sacroiliac joint pain. Anesthesiology. 2008 Aug;109(2):279-88.

Rupert MP, Lee M, Manchikanti L, Datta S, Cohen SP. Evaluation of sacroiliac joint interventions: a systematic appraisal of the literature. Pain Physician. 2009 Mar-Apr;12(2):399-418.

Peterson C, Hodler J. Evidence-based radiology (part 1): Is there sufficient research to support the use of therapeutic injections for the spine and sacroiliac joints? Skeletal Radiol. 2010 Jan;39(1):5-9.

Manchikanti L, Datta S, Derby R, Wolfer LR, Benyamin RM, Hirsch JA; American Pain Society. A critical review of the American Pain Society clinical practice guidelines for interventional techniques: part 1. Diagnostic interventions. Pain Physician. 2010 May-Jun;13(2):E141-74.