National Medical Policy

National Medical Policy Subject: Policy Number: Sacroiliac Joint Injections NMP66 Effective Date*: October 2003 Updated: July 2015 This National Medical Policy is subject to the terms in the IMPORTANT NOTICE at the end of this document For Medicaid Plans: Please refer to the appropriate Medicaid Manuals for coverage guidelines prior to applying Health Net Medical Policies The Centers for Medicare & Medicaid Services (CMS) For Medicare Advantage members please refer to the following for coverage guidelines first: Use Source Reference/Website Link National Coverage Determination (NCD) National Coverage Manual Citation X Local Coverage Determination (LCD)* Article (Local)* Epidural and Transforaminal Epidural Injections; Paravertebral Facet Joint Block and Facet Joint Denervation; Sacroiliac Joint Injections: http://www.cms.gov/medicare-coveragedatabase/search/advanced-search.aspx Other None Use Health Net Policy Instructions Medicare NCDs and National Coverage Manuals apply to ALL Medicare members in ALL regions. Medicare LCDs and Articles apply to members in specific regions. To access your specific region, select the link provided under Reference/Website and follow the Sacroiliac Joint Injections Jul 15 1

search instructions. Enter the topic and your specific state to find the coverage determinations for your region. *Note: Health Net must follow local coverage determinations (LCDs) of Medicare Administration Contractors (MACs) located outside their service area when those MACs have exclusive coverage of an item or service. (CMS Manual Chapter 4 Section 90.2) If more than one source is checked, you need to access all sources as, on occasion, an LCD or article contains additional coverage information than contained in the NCD or National Coverage Manual. If there is no NCD, National Coverage Manual or region specific LCD/Article, follow the Health Net Hierarchy of Medical Resources for guidance. Current Policy Statement Sacroiliac joint injections performed under fluoroscopy guidance are considered medically necessary when used either: 1. As a diagnostic trial to determine the origin of the pain; or 2. As a therapeutic injection for temporary relief of lower back pain in conjunction with other noninvasive treatment methods (e.g., to participate in physical therapy), and not as a stand-alone therapy. AND 3. All of the following are met: Patient has either acute or chronic lower back pain Pain is thought to be secondary to suspected sacroiliac joint disturbances Pain and disability are of moderate-to-severe degree Patient has been unresponsive to a 6-week course of conservative measures (e.g., oral medications, rest/limited activity, and/or physical therapy) Contraindications to receiving sacroiliac joint injections include, but are not limited to, the following: 1. Allergy to the medication to be administered 2. Anticoagulation therapy 3. Bleeding disorder 4. Localized infection in the region to be injected 5. Systemic infection 6. Other co-morbidities which could be exacerbated by the procedure/steroid usage (e.g., poorly controlled hypertension, severe congestive heart failure, diabetes, etc.) Codes Related To This Policy NOTE: The codes listed in this policy are for reference purposes only. Listing of a code in this policy does not imply that the service described by this code is a covered or noncovered health service. Coverage is determined by the benefit documents and medical necessity criteria. This list of codes may not be all inclusive. On October 1, 2015, the ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced by ICD-10 code sets. Health Net National Medical Policies will now include the preliminary ICD-10 codes in preparation for this Sacroiliac Joint Injections Jul 15 2

transition. Please note that these may not be the final versions of the codes and that will not be accepted for billing or payment purposes until the October 1, 2015 implementation date. ICD-9 Codes 720.2 Sacroiliitis 724.6 Disorders of sacrum (refers to this code for sacroiliac pain and chronic or old sacroiliac sprain) 846.1 Sprains and strains of sacroiliac ligament 846.8 Sprains and strains of other specified sites of sacroiliac region 846.9 Sprains and strains of unspecified site of sacroiliac region ICD 10 Codes M46.1 Sacroiliitis, not elsewhere classified M53.3 Sacrococcygeal disorders, not elsewhere classified S33.6 Sprain of sacroiliac joint S33.8 Sprain of other parts of lumbar spine and pelvis S33.9 Sprain of unspecified parts of lumbar spine and pelvis CPT Codes 27096 Injection procedure for sacroiliac joint, arthrography, and/or anesthetic/steroid 64493 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral, single level 64494 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral, second level 64495 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral, third and any additional level(s) 77001 Fluoroscopic guidance for central venous access device placement, replacement (catheter only or complete), or removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast injections through access site or catheter with related venography radiologic supervision and interpretation, and radiographic supervision and interpretation, and radiographic documentation of final catheter position) 77002 Fluoroscopic guidance for needle placement (eg. Biopsy, aspiration, injection, localization device) 77003 Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, subarachnoid, or sacroiliac joint), including neurolytic agent destruction HCPCS Codes J-code For anesthetic agent used J-code For steroid (if used in addition to anesthetic) Scientific Rationale Update July 2015 Sacroiliac Joint Injections Jul 15 3

Soneji et al (2015) reported that sacroiliac joint (SIJ) arthritis is a common cause of chronic mechanical low back pain (LBP) that is often treated with injection of local anesthetic and steroids. Ultrasound (US) has emerged as a viable alternative to fluoroscopy (FL) to guide SIJ injections; however, few studies have compared these modalities. In this prospective randomized, controlled trial, we compared both accuracy and efficacy of US and FL guidance for SIJ injections. Forty patients with chronic moderate-to-severe LBP secondary to SIJ arthritis were randomized to receive US- or FL-guided unilateral SIJ injections. Primary outcomes included pain at 1 month measured by numerical rating scale (NRS) scores. Secondary outcomes included NRS scores at 24 hours, 72 hours, 1 week, and 3 months after injection, physical functioning at 1 month after the procedure, procedure time, incidence of intra-articular and peri-articular needle placement, patient discomfort, overall patient satisfaction, and daily opioid consumption. There was no significant difference in NRS pain scores between the 2 groups at 1 month or at any other follow-up points. A significant reduction from baseline mean NRS scores was observed in both groups at 1 month after injection (US 22.7%, P = 0.025; FL 37.3%, P < 0.001). There was no significant difference in procedure-related variables, physical functioning, discomfort, opioid utilization, and patient satisfaction between the 2 groups. The authors concluded ultrasound-guided SIJ injection with fluoroscopic confirmation has similar accuracy and efficacy to fluoroscopy alone for SIJ injections in patients with chronic low back pain secondary to SIJ arthritis. Chou et al (2015) reviewed the current evidence on effectiveness and harms of epidural, facet joint, and sacroiliac corticosteroid injections for low back pain conditions. The authors used predefined criteria, and selected randomized trials of patients with lumbosacral radiculopathy, spinal stenosis, nonradicular back pain, or chronic postsurgical back pain that compared effectiveness or harms of epidural, facet joint, or sacroiliac corticosteroid injections versus placebo or other interventions. They also included randomized trials that compared different injection techniques and large (sample sizes >1000) observational studies of back injections that reported harms. The quality of included studies was assessed, data were extracted, and results were summarized qualitatively and using meta-analysis on outcomes stratified by immediate- (1 week to 2 weeks), short- (2 weeks to 3 months), intermediate- (3 months to <1 year), and long-term (>1 year) follow-up. Seventy-eight randomized trials of epidural injections, 13 trials of facet joint injections, and one trial of sacroiliac injections were included. For epidural corticosteroid injections versus placebo interventions for radiculopathy, the only statistically significant effects were on mean improvement in pain at immediate-term follow-up (weighted mean difference [WMD] 7.55 on a 0 to 100 scale, 95% CI 11.4 to 3.74) (strength of evidence [SOE]: moderate), mean improvement in function at immediate-term follow-up when an outlier trial was excluded (standardized mean difference [SMD] 0.33, 95% CI 0.56 to 0.09) (SOE: low), and risk of surgery at short-term follow-up (relative risk [RR] 0.62, 95% CI 0.41 to 0.92) (SOE: low). The magnitude of effects on pain and function was small, did not meet predefined thresholds for minimum clinically important differences, and there were no differences on outcomes at longer-term follow up. Evidence on effects of different injection techniques, patient characteristics, or comparator interventions estimates was limited and did not show clear effects. Trials of epidural corticosteroid injections for radiculopathy versus nonplacebo interventions did not clearly demonstrate effectiveness (SOE: insufficient to low). Evidence was limited for epidural corticosteroid injections versus placebo interventions for spinal stenosis (SOE: low to moderate) or nonradicular back pain (SOE: low), but showed no differences in pain, function, or likelihood of surgery. Studies found no clear Sacroiliac Joint Injections Jul 15 4

differences between various facet joint corticosteroid injections (intra-articular, extra-articular [peri-capsular], or medial branch) and placebo interventions (SOE: low to moderate). There was insufficient evidence from one very small trial to determine effects of peri-articular sacroiliac joint corticosteroid injections injection (SOE: insufficient). Serious harms from injections were rare in randomized trials and observational studies, but harms reporting was suboptimal (SOE: low). The reviewers concluded epidural corticosteroid injections for radiculopathy were associated with immediate improvements in pain and might be associated with immediate improvements in function, but benefits were small and not sustained, and there was no effect on long-term risk of surgery. Evidence did not suggest that effectiveness varies based on injection technique, corticosteroid, dose, or comparator. Limited evidence suggested that epidural corticosteroid injections are not effective for spinal stenosis or nonradicular back pain and that facet joint corticosteroid injections are not effective for presumed facet joint pain. There was insufficient evidence to evaluate effectiveness of sacroiliac joint corticosteroid injections. Scientific Rationale Update July 2014 Facet joint interventions and sacroiliac joint interventions are utilized in managing facet joint and sacroiliac joint pain. According to the American Society of Interventional Pain Physicians (2013), The evidence for diagnostic lumbar facet joint nerve blocks and diagnostic sacroiliac intraarticular injections is good with 75% to 100% pain relief as criterion standard with controlled local anesthetic or placebo blocks. Visser et al (2013) assessed which treatment is successful for sacroiliac joint (SIJ)- related back and leg pain. Using a single-blinded randomised trial, the authors assessed the short-term therapeutic efficacy of physiotherapy, manual therapy, and intra-articular injection with local corticosteroids in the SIJ in 51 patients with SIJrelated leg pain. The effect of the treatment was evaluated after 6 and 12 weeks. Of the 51 patients, 25 (56 %) were successfully treated. Physiotherapy was successful in 3 out of 15 patients (20 %), manual therapy in 13 of the 18 (72 %), and intra-articular injection in 9 of 18 (50 %) patients (p = 0.01). Manual therapy had a significantly better success rate than physiotherapy (p = 0.003). The authors concluded in the small single-blinded prospective study, manual therapy appeared to be the choice of treatment for patients with SIJ-related leg pain. A second choice of treatment to be considered is an intra-articular injection. Manchikanti et al (2013) analyzed the growth patterns of sacroiliac joint injections in Medicare beneficiaries from 2000 to 2011. This assessment was performed utilizing Centers for Medicare and Medicaid Services (CMS) Physician/Supplier Procedure Summary (PSPS) Master data from 2000 to 2011. The findings of the assessment in Medicare beneficiaries from 2000 to 2011 showed a 331% increase per 100,000 Medicare beneficiaries with an annual increase of 14.2%, compared to an increase in the Medicare population of 23% or annual increase of 1.9%. The number of procedures increased from 49,554 in 2000 to 252,654 in 2011, or a rate of 125 to 539 per 100,000 Medicare beneficiaries. Among the various specialists performing sacroiliac joint injections, physicians specializing in physical medicine and rehabilitation have shown the most increase, followed by neurology with 1,568% and 698%, even though many physicians from both specialties have been enrolling in interventional pain management and pain management. Even though the numbers were small for nonphysician providers including certified registered nurse anesthetists, nurse practitioners, and physician assistants, these numbers increased Sacroiliac Joint Injections Jul 15 5

substantially at a rate of 4,526% per 100,000 Medicare beneficiaries with 21 procedures performed in 2000 increasing to 4,953 procedures in 2011. The, majority of sacroiliac joint injections were performed in an office setting. The utilization of sacroiliac joint injections by state from 2008 to 2010 showed increases of more than 20% in New Hampshire, Alabama, Minnesota, Vermont, Oregon, Utah, Massachusetts, Kansas, and Maine. Similarly, some states showed significant decreases of 20% or more, including Oklahoma, Louisiana, Maryland, Arkansas, New York, and Hawaii. Overall, there was a 1% increase per 100,000 Medicare population from 2008 to 2010. However, 2011 showed significant increases from 2010. The limitations of the study included a lack of inclusion of Medicare participants in Medicare Advantage plans, the availability of an identifiable code for only sacroiliac joint injections, and the possibility that state claims data may include claims from other states. The authors concluded the study illustrates the explosive growth of sacroiliac joint injections even more than facet joint interventions. Furthermore, certain groups of providers showed substantial increases. Overall, increases from 2008 to 2010 were nominal with 1%, but some states showed over 20% increases whereas some others showed over 20% decreases. Scientific Rationale - Update January 2014 Jee H, et al (2013) compared the short-term effects and safety of ultrasound (US)- guided sacroiliac joint (SIJ) injections with fluoroscopy (FL)-guided SIJ injections in patients with noninflammatory SIJ dysfunction in a prospective, randomized controlled trial at a single hospital. Patients (N=120) with noninflammatory sacroiliac arthritis were enrolled. All procedures were performed using an FL or US apparatus. Subjects were randomly assigned to either the FL or US group. Immediately after the SIJ injections, fluoroscopy was applied to verify the correct placement of the injected medication and intravascular injections. Main outcomes measured treatment effects and functional improvement were compared at 2 and 12 weeks after the procedures. The verbal numeric pain scale and Oswestry Disability Index improved at 2 and 12 weeks after the injections without statistical significances between groups. Of 55 US-guided injections, 48 (87.3%) were successful and 7 (12.7%) were missed. The FL-guided SIJ approach exhibited a greater accuracy (98.2%) than the US-guided approach. Vascularization around the SIJ was seen in 34 of 55 patients. Among the 34 patients, 7 had vascularization inside the joint, 23 had vascularization around the joint, and 4 had vascularization both inside and around the joint. Three cases of intravascular injections occurred in the FL group. Investigators concluded the US-guided approach may facilitate the identification and avoidance of the critical vessels around or within the SIJ. Function and pain relief significantly improved in both groups without significant differences between groups. The US-guided approach was shown to be as effective as the FLguided approach in treatment effects. However, diagnostic application in the SIJ may be limited because of the significantly lower accuracy rate (87.3%). Visser et al (2013) assessed which treatment is successful for SIJ-related back and leg pain. Using a single-blinded randomized trial, the investigators assessed the short-term therapeutic efficacy of physiotherapy, manual therapy, and intra-articular injection with local corticosteroids in the SIJ in 51 patients with SIJ-related leg pain. The effect of the treatment was evaluated after 6 and 12 weeks. Of the 51 patients, 25 (56 %) were successfully treated. Physiotherapy was successful in 3 out of 15 patients (20 %), manual therapy in 13 of the 18 (72 %), and intra-articular injection in 9 of 18 (50 %) patients. Manual therapy had a significantly better success rate than physiotherapy. Investigators concluded in this small single-blinded prospective Sacroiliac Joint Injections Jul 15 6

study, manual therapy appeared to be the choice of treatment for patients with SIJrelated leg pain. A second choice of treatment to be considered is an intra-articular injection. An evidence-based clinical practice guidelines for interventional techniques in the diagnosis and treatment of chronic spinal pain (Manchikanti el al 2013) reported regarding the lumbar spine, The evidence for accuracy of diagnostic selective nerve root blocks is limited; whereas for lumbar provocation discography, it is fair. The evidence for diagnostic lumbar facet joint nerve blocks and diagnostic sacroiliac intraarticular injections is good with 75% to 100% pain relief as criterion standard with controlled local anesthetic or placebo blocks. The reviewers note further, For sacroiliac joint interventions, the evidence for cooled radiofrequency neurotomy is fair; limited for intraarticular injections and periarticular injections; and limited for both pulsed radiofrequency and conventional radiofrequency neurotomy. Scientific Rationale Update January 2013 Simopoulos et al (2012) evaluated the accuracy of diagnostic sacroiliac joint interventions in a systematic review. Methodological quality assessment of included studies was performed using Quality Appraisal of Reliability Studies (QAREL). Only diagnostic accuracy studies meeting at least 50% of the designated inclusion criteria were utilized for analysis. Studies scoring less than 50% are presented descriptively and analyzed critically. The level of evidence was classified as good, fair, or poor based on the quality of evidence developed by the United States Preventive Services Task Force (USPSTF). Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to December 2011, and manual searches of the bibliographies of known primary and review articles. In this evaluation the reviewers utilized controlled local anesthetic blocks using at least 50% pain relief as the reference standard. They reported the evidence is good for the diagnosis of sacroiliac joint pain utilizing controlled comparative local anesthetic blocks. The prevalence of sacroiliac joint pain is estimated to range between 10% and 62% based on the setting; however, the majority of analyzed studies suggest a point prevalence of around 25%, with a false-positive rate for uncontrolled blocks of approximately 20%. The evidence for provocative testing to diagnose sacroiliac joint pain was fair. The evidence for the diagnostic accuracy of imaging is limited. Reviewers noted the limitations of this systematic review include a paucity of literature, variations in technique, and variable criterion standards for the diagnosis of sacroiliac joint pain. Hansen et al (2012) performed a systematic review to evaluate the accuracy of therapeutic sacroiliac joint interventions. The available literature on therapeutic sacroiliac joint interventions in managing chronic low back and lower extremity pain was reviewed. The quality assessment and clinical relevance criteria utilized were the Cochrane Musculoskeletal Review Group criteria for randomized trials of interventional techniques and the criteria developed by the Newcastle-Ottawa Scale for observational studies. The level of evidence was classified as good, fair, or poor based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Data sources included relevant literature published from 1966 through December 2011 that was identified through searches of PubMed and EMBASE, and manual searches of the bibliographies of known primary and review articles. The primary outcome measure was pain relief (short-term relief = up to 6 months and long-term > 6 months). Secondary outcome measures were improvement in functional status, psychological status, return to work, and reduction in opioid intake. For this systematic review, 56 studies were considered for Sacroiliac Joint Injections Jul 15 7

inclusion. Of these, 45 studies were excluded and a total of 11 studies met inclusion criteria for methodological quality assessment with 6 randomized trials and 5 nonrandomized studies. The evidence for cooled radiofrequency neurotomy in managing sacroiliac joint pain is fair.the evidence for effectiveness of intraarticular steroid injections is poor.the evidence for periarticular injections of local anesthetic and steroid or botulinum toxin is poor. The evidence for effectiveness of conventional radiofrequency neurotomy is poor. The evidence for pulsed radiofrequency is poor. Reviewers noted the limitations of this systematic review include a paucity of literature on therapeutic interventions, variations in technique, and variable diagnostic standards for sacroiliac joint pain. They concluded the evidence was fair in favor of cooled radiofrequency neurotomy and poor for short-term and long-term relief from intraarticular steroid injections, periarticular injections with steroids or botulin toxin, pulsed radiofrequency, and conventional radiofrequency neurotomy. Plastaras et al (2012) described the type, incidence, and factors that contribute to adverse events associated with fluoroscopically guided intra-articular sacroiliac joint injections (IASIJ) in a retrospective cohort study at a tertiary, academic, outpatient physical medicine and rehabilitation interventional spine clinic. Included in the study were English-speaking adults aged 18-90 years who underwent fluoroscopically guided IASIJ injections between March 8, 2004, and April 19, 2007. After IASIJ injections, 3 senior researchers recorded the presence and types of adverse events. The relationship of adverse events with age, gender, fluoroscopy time, vital signs, and trainee presence was analyzed with the Fisher exact or the Wilcoxon rank sum 2-sided tests. The frequency of immediate (during or immediately after the procedure) or delayed (within 24-72 hours after the procedure) adverse events. A total of 162 patients (133 women) underwent 191 procedures. The range of subject age was from 20 to 90 years (15.8 years, standard deviation [SD]). The range (SD) of the preprocedure 11-point Likert Pain Scale was from 1.0 to 10.0 (2.0) and for the postprocedure 11-point Likert Pain Scale was from 0.0 to 9.0 (2.5). Trainees were involved in 57% of the procedures. Reported immediate adverse events were vasovagal reaction (2.1% [n = 4]) and steroid-clogged needle (0.5% [n = 1]). Follow-up data were available for 132 of 191 procedures (69%). There were 32 adverse events reported at a mean follow-up interval of 2 days, of which, the most frequent adverse events were injection-site soreness (12.9% [n = 17]), pain exacerbation (5.3% [n = 7]), and facial flushing and/or sweating (2.3% [n = 3]). Delayed adverse events decreased with older age (P =.0029). The patients who underwent bilateral procedures experienced more delayed adverse events than the patients who underwent unilateral procedures (P =.024). Investigators concluded fluoroscopically guided IASIJ injection is associated with minimal adverse effects. The most common immediate adverse event was vasovagal reaction, and the most common delayed adverse event was injection-site soreness. Younger age is significantly related to reported delayed adverse events. Scientific Rationale The sacroiliac joint is located in the lower spine above the coccyx. To this day there is substantial controversy over the existence and clinical relevance of painful sacroiliac joint dysfunction. It is known that inflammation of the sacroiliac joint can cause lower back and buttock pain, however, it is often overlooked as a source of low back pain. Patient history in most cases fails to reveal a significant primary event, physical examination is difficult because of its anatomical location and many of the provocative tests place mechanical stresses on structures that surround it. The diagnosis remains as one of exclusion. Sacroiliac Joint Injections Jul 15 8

The sacroiliac facet joints are small joints in the region of the low back and buttocks where the pelvis actually joins with the spine. Sacroiliac dysfunction, also called sacroiliac joint mechanical pain or sacroiliac joint syndrome, is the most common painful condition of this joint. It is now recognized that the sacroiliac joint possesses widespread neural innervation, anatomic variability, and unique biomechanical properties. Although not usually a primary pain generator, the sacroiliac joint can also be a common area of referred pain and can persist as the primary focus of pain. The typical pain referral pattern is to an area around and just caudal to the posterior superior iliac spine (e.g., buttocks). By placing a local anesthetic into the joint, immediate pain relief experienced will help confirm or deny the joint as a source of pain. Treatment for sacroiliac joint dysfunction is usually conservative (non-surgical) and focuses on trying to restore normal motion in the joint. In patients who have failed 4 to 6 weeks of a comprehensive exercise program, local icing, mobilization/manipulation and oral anti-inflammatory medications (NSAIDS), a sacroiliac joint injection can be helpful for both diagnostic and therapeutic purposes. Sacroiliac joint injections into the synovial sac of the sacroiliac joint may provide immediate and significant pain relief. At least 75% resolution of the patient s pain over the ipsilateral SI joint is considered diagnostic of pain emanating from the sacroiliac joint. Adding a steroid to the solution injected may help to reduce any inflammation that may exist within the joint(s) and result in a prolonged period of freedom from pain. For the treatment to be successful, the injection should be followed by physical therapy and/or chiropractic manipulations to provide mobilization and range of motion exercises. The frequency of these injections should be limited with attention placed on the comprehensive exercise program. Depending on the response to the blockade, patients who experience continued pain may qualify for a more permanent procedure, such as radiofrequency lesioning or the intraarticular injection of phenol 6%. There are no prospective or controlled studies published. No literature is available to show how helpful sacroiliac joint injections are for the differentiation of sacroiliac arthropathy from facet joint disease, myofascial pain, or discogenic pain. One followup series of 35 patients diagnostically injected with local anesthetic reported 7 with persistent improvement of more than 75% pain relief at 6 months after injection of therapeutic corticosteroids. Review History October 16, 2003 April 2006 March 2007 April 2008 April 2011 January 2012 January 2013 January 2014 July 2014 July 2015 Medical Advisory Council Update no revisions Coding Updates Update no revisions Update no revisions. Code Updates Update no revisions Update no revisions. Code updates Update - no revisions Update no revisions Update no revisions This policy is based on the following evidence-based guidelines: 1. Boswell MV, Trescot AM, Datta S. et al. Interventional techniques: evidencebased practice guidelines in the management of chronic spinal pain. Pain Phys Sacroiliac Joint Injections Jul 15 9

2007 Jan;10(1):7-111. Available at: http://www.asipp.org/documents/guidelines2007.pdf 2. American Society of Anesthesiologists Task Force on Chronic Pain Management, American Society of Regional Anesthesia and Pain Medicine. 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. Anesthesiology 2010 Apr;112(4):810-33. 3. Manchikanti L, Abdi S, Atluri S, et al. An update of comprehensive evidencebased guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain Physician. 2013 Apr;16(2 Suppl):S49-283. Available at: http://www.painphysicianjournal.com/2013/april/2013;16;s49-s283.pdf 4. Health Technology Brief. Sacroiliac Joint Injections with Corticosteroids for Treatment of Chronic Low Back Pain. Oct 2014 References Update July 2015 1. Althoff CE, Bollow M, Feist E, et al. CT-guided corticosteroid injection of the sacroiliac joints: quality assurance and standardized prospective evaluation of long-term effectiveness over six months. Clin Rheumatol. 2015 Jun;34(6):1079-84 2. Chou R, Hashimoto R, Friedly J, et al. Pain Management Injection Therapies for Low Back Pain [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2015 Mar 20. 3. D'Orazio F, Gregori LM, Gallucci M. Spine epidural and sacroiliac joints injections--when and how to perform. Eur J Radiol. 2015 May;84(5):777-82. 4. Manchikanti L, Pampati V, Falco FJ, Hirsch JA. An updated assessment of utilization of interventional pain management techniques in the Medicare population: 2000-2013. Pain Physician. 2015 Mar-Apr;18(2):E115-27. 5. Soneji N, Bhatia A, Seib R, et al. Comparison of Fluoroscopy and Ultrasound Guidance for Sacroiliac Joint Injection in Patients with Chronic Low Back Pain. Pain Pract. 2015 May 19 References Update July 2014 1. Cohen SP, Hameed H, Kurihara C, et al. The effect of sedation on the accuracy and treatment outcomes for diagnostic injections: a randomized, controlled, crossover study. Pain Med. 2014 Apr;15(4):588-602. 2. Jee H, Lee JH, Park KD, et al. Ultrasound-guided versus fluoroscopy-guided sacroiliac joint intra-articular injections in the noninflammatory sacroiliac joint dysfunction: a prospective, randomized, single-blinded study. Arch Phys Med Rehabil. 2014 Feb;95(2):330-7. 3. Manchikanti L, Hansen H, Pampati V, Falco FJ. Utilization and growth patterns of sacroiliac joint injections from 2000 to 2011 in the medicare population. Pain Physician. 2013 Jul-Aug;16(4):E379-90. 4. Visser LH, Woudenberg NP, de Bont J, et al. Treatment of the sacroiliac joint in patients with leg pain: a randomized-controlled trial. Eur Spine J. 2013 Oct;22(10):2310-7. 5. Zacchino M, Almolla J, Canepari E, et al. Use of ultrasound-magnetic resonance image fusion to guide sacroiliac joint injections: a preliminary assessment. J Ultrasound. 2013 Jul 31;16(3):111-8. References Update January 2014 Sacroiliac Joint Injections Jul 15 10

1. Jee H, Lee JH, Park KD, et al. Ultrasound-Guided Versus Fluoroscopy-Guided Sacroiliac Joint Intra-articular Injections in the Noninflammatory Sacroiliac Joint Dysfunction: A Prospective, Randomized, Single-Blinded Study. Arch Phys Med Rehabil. 2013 Oct 9. 2. Manchikanti L, Hansen H, Pampati V, Falco FJ. Utilization and growth patterns of sacroiliac joint injections from 2000 to 2011 in the medicare population. Pain Physician. 2013 Jul-Aug;16(4):E379-90. 3. Manchikanti L, Abdi S, Atluri S, et al. An update of comprehensive evidencebased guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain Physician. 2013 Apr;16(2 Suppl):S49-283 4. Visser LH, Woudenberg NP, de Bont J, et al. Treatment of the sacroiliac joint in patients with leg pain: a randomized-controlled trial. Eur Spine J. 2013 Oct;22(10):2310-7. References Update January 2013 1. Artner J, Cakir B, Reichel H, Lattig F. Radiation dose reduction in CT-guided sacroiliac joint injections to levels of pulsed fluoroscopy: a comparative study with technical considerations. J Pain Res. 2012;5:265-9. 2. Hansen H, Manchikanti L, Simopoulos TT, et al. A systematic evaluation of the therapeutic effectiveness of sacroiliac joint interventions. Pain Physician. 2012 May-Jun;15(3):E247-78. 3. Plastaras CT, Joshi AB, Garvan C, et al. Adverse events associated with fluoroscopically guided sacroiliac joint injections. PM R. 2012 Jul;4(7):473-8 4. Simopoulos TT, Manchikanti L, Singh V, et al. A systematic evaluation of prevalence and diagnostic accuracy of sacroiliac joint interventions. Pain Physician. 2012 May-Jun;15(3):E305-44. References Update January 2012 1. Gupta S. Double needle technique: an alternative method for performing difficult sacroiliac joint injections. Pain Physician. 2011 May-Jun;14(3):281-4. 2. Kim WM, Lee HG, Jeong CW, et al. A randomized controlled trial of intraarticular prolotherapy versus steroid injection for sacroiliac joint pain J Altern Complement Med. 2010 Dec;16(12):1285-90. References Update April 2011 1. Manchikanti L, Boswell MV, Singh V, et al. Comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician. 2009 Jul-Aug;12(4):699-802 2. Manchikanti L, Datta S, Gupta S, et al. A critical review of the American Pain Society clinical practice guidelines for interventional techniques: part 2. Therapeutic interventions. Pain Physician. 2010 Jul;13(4):E215-64. 3. Poley RE, Borchers JR. Sacroiliac joint dysfunction: evaluation and treatment. Phys Sportsmed. 2008 Dec;36(1):42-9. 4. Rupert MP, Lee M, Manchikanti L, et al. Evaluation of sacroiliac joint interventions: a systematic appraisal of the literature. Pain Physician. 2009 Mar- Apr;12(2):399-4 References Update April 2008 1. Hansen HC, McKenzie-Brown AM, Cohen SP, et al. Sacroiliac joint interventions: a systematic review. Pain Physician. 2007 Jan;10(1):165-84. 2. McKenzie-Brown AM, Shah RV, Sehgal N, Everett CR. A systematic review of sacroiliac joint interventions. Pain Physician. 2005 Jan;8(1):115-25. Sacroiliac Joint Injections Jul 15 11

References 1. Bigos SJ, Bowyer OR, Braen RG, et al. "Acute low back problems in adults. Clinical Practice Guideline. Number 14. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research (AHCPR). AHCPR publication number 95-0642: December 1994. Available at: http://hstat.nlm.nih.gov/hq/hquest/db/local.arahcpr.arclin.lbpc/screen/doctitle/s /49637 2. Manchikanti L, Singh V, Kloth D. American Society of Interventional Pain Physicians. Interventional Pain Management Practice Policies. Available at: http://www.asipp.org/documents/pdf/practice_policies.pdf 3. American Society of Anesthesiologists. Task Force on Pain Management, Chronic Pain Section. Practice guidelines for chronic pain management. 1997. 4. Pekkafahli MZ, Kiralp MZ, Basekim CC, et al. Sacroiliac joint injections performed with sonographic guidance. J Ultrasound Med. 2003 Jun;22(6):553-9. 5. Laslett M, Young SB, Aprill CN, McDonald B. Diagnosing painful sacroiliac joints: A validity study of a McKenzie evaluation and sacroiliac provocation tests. Aust J Physiother. 2003;49(2):89-97. 6. Stallmeyer MJ, Ortiz AO. Facet blocks and sacroiliac joint injections. Tech Vasc Interv Radiol. 2002 Dec;5(4):201-6. 7. Saal JS. General principles of diagnostic testing as related to painful lumbar spine disorders: a critical appraisal of current diagnostic techniques. Spine. 2002 Nov 15;27(22):2538-45; discussion 2546. 8. Manchikanti L, Singh V, Kloth D et al. Interventional techniques in the management of chronic pain: Part 2.0. Pain Physician 2001; 4:24-96. 9. Slipman CW, Whyte WS, Chow DW et al. Sacroiliac joint syndromes. Pain Physician 2001; 4:143-152. 10. Slipman CW, Lipetz JS, Plastaras CT, et al. Fluoroscopically guided therapeutic sacroiliac joint injections for sacroiliac joint syndrome. Am J Phys Med Rehabil. 2001 Jun;80(6):425-32. 11. Calvillo O, Skaribas I, Turnipsee. Anatomy and pathophysiology of the sacroiliac joint. Curr Rev Pain. 2000;4(5):356-61. 12. Slipman CW, Jackson HB, Lipetz JS, et al. Sacroiliac joint pain referral zones. Arch Phys Med Rehabil. 2000 Mar;81(3):334-8. 13. Dussault RG, Kaplan PA, Anderson MW. Fluoroscopy-guided sacroiliac joint injections. Radiology. 2000 Jan;214(1):273-7. 14. Fortin JD, Kissling RO, O'Connor BL, Vilensky JA. Sacroiliac joint innervation and pain. Am J Orthop. 1999 Dec;28(12):687-90. 15. Bigot J, Loeuille D, Chary-Valckenaere I, et al. Determination of the best diagnostic criteria of sacroiliitis with MRI. J Radiol. 1999 Dec;80(12):1649-57. 16. Fortin JD, Kissling RO, O'Connor BL, Vilensky JA. Sacroiliac joint innervation and pain. Am J Orthop 1999;28:687-690. 17. Wybier M, Parlier-Cuau C, Champsaur P, et al. Steroid Injection of the Appendicular Skeleton and Sacroiliac Joints. Semin Musculoskelet Radiol. 1997;1(2):241-250. 18. Dreyfuss P, Michaelsen M, Pauza K et al. The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine 1996; 21:2594-2602. 19. Maigne JY, Aivaliklis A, Pfefer F. Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain. Spine 1996; 21:1889-1892. Sacroiliac Joint Injections Jul 15 12

20. Slipman CW, Plastaras CT, Yang ST et al. Outcomes of therapeutic fluoroscopically guided sacroiliac joint injections for definitive SIJS. Arch Phys Med Rehabil 1996; 77:937. 21. Fortin JD, Dwyer A, West S et al. Sacroiliac joint pain referral patterns upon application of a new injection/arthrography technique. Part I: Asymptomatic volunteers. Spine 1994; 19:1475-1482. 22. Fortin JD, Dwyer A, Aprill C et al. Sacroiliac joint pain referral patterns. Part II: Clinical evaluation. Spine 1994; 19:1483-1489. 23. Dreyfuss P, Dreyer S, Griffin J et al. Positive sacroiliac screening tests in asymptomatic adults. Spine 1994; 19:1138-1143. 24. Fortin JD. The sacroiliac joint: A new perspective. J Back Musculoskeletal Rehabil 1993; 3:31-43. Important Notice General Purpose. Health Net's National Medical Policies (the "Policies") are developed to assist Health Net in administering plan benefits and determining whether a particular procedure, drug, service or supply is medically necessary. The Policies are based upon a review of the available clinical information including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the drug or device, evidence-based guidelines of governmental bodies, and evidence-based guidelines and positions of select national health professional organizations. Coverage determinations are made on a case-by-case basis and are subject to all of the terms, conditions, limitations, and exclusions of the member's contract, including medical necessity requirements. Health Net may use the Policies to determine whether under the facts and circumstances of a particular case, the proposed procedure, drug, service or supply is medically necessary. The conclusion that a procedure, drug, service or supply is medically necessary does not constitute coverage. The member's contract defines which procedure, drug, service or supply is covered, excluded, limited, or subject to dollar caps. The policy provides for clearly written, reasonable and current criteria that have been approved by Health Net s National Medical Advisory Council (MAC). The clinical criteria and medical policies provide guidelines for determining the medical necessity criteria for specific procedures, equipment, and services. In order to be eligible, all services must be medically necessary and otherwise defined in the member's benefits contract as described this "Important Notice" disclaimer. In all cases, final benefit determinations are based on the applicable contract language. To the extent there are any conflicts between medical policy guidelines and applicable contract language, the contract language prevails. Medical policy is not intended to override the policy that defines the member s benefits, nor is it intended to dictate to providers how to practice medicine. Policy Effective Date and Defined Terms. The date of posting is not the effective date of the Policy. The Policy is effective as of the date determined by Health Net. All policies are subject to applicable legal and regulatory mandates and requirements for prior notification. If there is a discrepancy between the policy effective date and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. * In some states, prior notice or posting on the website is required before a policy is deemed effective. For information regarding the effective dates of Policies, contact your provider representative. The Policies do not include definitions. All terms are defined by Health Net. For information regarding the definitions of terms used in the Policies, contact your provider representative. Policy Amendment without Notice. Health Net reserves the right to amend the Policies without notice to providers or Members. In some states, prior notice or website posting is required before an amendment is deemed effective. No Medical Advice. The Policies do not constitute medical advice. Health Net does not provide or recommend treatment to members. Members should consult with their treating physician in connection with diagnosis and treatment decisions. No Authorization or Guarantee of Coverage. The Policies do not constitute authorization or guarantee of coverage of particular procedure, drug, service or supply. Members and providers should refer to the Member contract to determine if exclusions, limitations, and dollar caps apply to a particular procedure, drug, service or supply. Policy Limitation: Member s Contract Controls Coverage Determinations. Statutory Notice to Members: The materials provided to you are guidelines used by this plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary Sacroiliac Joint Injections Jul 15 13

depending on individual need and the benefits covered under your contract. The determination of coverage for a particular procedure, drug, service or supply is not based upon the Policies, but rather is subject to the facts of the individual clinical case, terms and conditions of the member s contract, and requirements of applicable laws and regulations. The contract language contains specific terms and conditions, including pre-existing conditions, limitations, exclusions, benefit maximums, eligibility, and other relevant terms and conditions of coverage. In the event the Member s contract (also known as the benefit contract, coverage document, or evidence of coverage) conflicts with the Policies, the Member s contract shall govern. The Policies do not replace or amend the Member s contract. Policy Limitation: Legal and Regulatory Mandates and Requirements The determinations of coverage for a particular procedure, drug, service or supply is subject to applicable legal and regulatory mandates and requirements. If there is a discrepancy between the Policies and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. Reconstructive Surgery CA Health and Safety Code 1367.63 requires health care service plans to cover reconstructive surgery. Reconstructive surgery means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) To improve function or (2) To create a normal appearance, to the extent possible. Reconstructive surgery does not mean cosmetic surgery," which is surgery performed to alter or reshape normal structures of the body in order to improve appearance. Requests for reconstructive surgery may be denied, if the proposed procedure offers only a minimal improvement in the appearance of the enrollee, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery. Reconstructive Surgery after Mastectomy California Health and Safety Code 1367.6 requires treatment for breast cancer to cover prosthetic devices or reconstructive surgery to restore and achieve symmetry for the patient incident to a mastectomy. Coverage for prosthetic devices and reconstructive surgery shall be subject to the co-payment, or deductible and coinsurance conditions, that are applicable to the mastectomy and all other terms and conditions applicable to other benefits. "Mastectomy" means the removal of all or part of the breast for medically necessary reasons, as determined by a licensed physician and surgeon. Policy Limitations: Medicare and Medicaid Policies specifically developed to assist Health Net in administering Medicare or Medicaid plan benefits and determining coverage for a particular procedure, drug, service or supply for Medicare or Medicaid members shall not be construed to apply to any other Health Net plans and members. The Policies shall not be interpreted to limit the benefits afforded Medicare and Medicaid members by law and regulation. Sacroiliac Joint Injections Jul 15 14