Highmark Medical Policy Bulletin |
Section: | Miscellaneous |
Number: | Z-62 |
Topic: | Sacroiliac Joint Injections |
Effective Date: | October 10, 2011 |
Issued Date: | October 10, 2011 |
Date Last Reviewed: | 07/2011 |
Indications and Limitations of Coverage
Sacroiliac (SI) joint arthrography using fluoroscopic guidance with injection (27096, 73542, 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. Arthrography of the sacroiliac joint with injection for diagnostic or therapeutic purposes or for the treatment of acute, subacute, or chronic back pain or radicular syndromes is considered experimental/investigational and therefore, not eligible for payment. 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 is considered experimental/investigational and therefore, not eligible for payment. A participating, preferred, or network provider can bill the member for the non-covered service. 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. |
|
27096 | 73542 | 77003 | G0260 |
Traditional (UCR/Fee Schedule) Guidelines
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. |
Comprehensive / Wraparound / PPO / Major Medical Guidelines
Any reference in this bulletin to non-billable services by a network provider may not be applicable to Major Medical.
Managed Care (HMO/POS) Guidelines
PRN
06/2011, Sacroiliac joint injections not covered |
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. |