Medical Affairs Policy Service: Sacroiliac Joint Treatments and Coccydynia Injections: Sacroiliac Joint Injections, Sacroiliac Joint Ablation, Sacroiliac Neuroablation, Sacroiliac Fusion, Lateral Branch Nerve Block for SI joint pain PUM 250-0024 Implemented 01/01/16 Arise/WPS Policy 09/12/14, 09/11/15 Committee Approval Reviewed 09/12/14, 09/11/15 Revised 09/12/14 Developed Note: See previous Coverage Policy Bulletin or Medical Affairs Policy and Procedure for review/revision history prior to 2014 Disclaimer: This policy is for informational purposes only and does not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may not provide coverage for all services listed in this policy. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by Wisconsin Physicians Service and Arise Health Plan (WPS/AHP) may not utilize WPS/AHP medical policy in all their coverage determinations. Contact customer services as listed on the member card for specific plan, benefit, and network status information. Medical policies are based on constantly changing medical science and are reviewed annually and subject to change. WPS/AHP uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG Health to assist in administering health benefits. This medical policy and MCG Health guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider. To obtain additional information about MCG email to medical.policies@wpsic.com. Note that many member certificates limit SI injections to only one per calendar year. In the absence of member certificate language regarding injection limits per calendar year, a year* is defined as 12 consecutive months from the time of the first injection. Description: Sacroiliac (SI) joint injection is an injection of local anesthetic and / or a steroid into the articular space between the spinal column and pelvis. SI joint pain is usually described as low back and buttock pain. The symptoms are related to an inflammatory process in the joint between the spinal column and pelvis. Injections have been performed for both Page 1 of 7
diagnostic and therapeutic purposes. If there is no relief of symptoms following an injection, it can be assumed that the symptoms are due to a different pain generator. Other interventions that have been proposed to treat SI joint pain include Sacroiliac Joint Ablation, Sacroiliac Neuroablation, Sacroiliac Fusion, and Lateral (Sacral) Branch Nerve Blocks Coccydynia (pain in the coccyx) is most commonly the result of a falling backwards into a sitting position. Most cases resolve without medical care or with conservative management although symptoms may take weeks to months to resolve. A minority of patients develop chronic coccydynia and may be referred to pain management specialists who may offer injections. Injections of coccygeal structures, guided by fluoroscopy, with either local anesthetic or local anesthetic plus corticosteroids are directed at the sacrococcygeal junction, the caudal epidural space, or the ganglion impar, a midline sympathetic ganglion located just anterior to the sacro-coccygeal junction. Indications of Coverage: 1. Sacroiliac joint injections are considered medically necessary if all of the following conditions are met: A. Chronic back and buttock pain symptoms (at least three months in duration). The nerve root tension test (straight leg raise), if performed, must be negative. B. Symptoms that have failed to respond to a one-month trial of more conservative therapies including anti-inflammatory medications (or other analgesic medication if the anti-inflammatory medication is contraindicated) used on a regular basis and physical and/or chiropractic therapy performed at some point after the onset of the current episode of symptoms. If the symptoms are severe (requiring urgent medical care), the trial of conservative therapy may not be required. If the above criteria are met, allow an initial sacroiliac joint injection. If the individual has experienced a reduction in pain symptoms of at least 50% for at least one week following the initial sacroiliac joint injection, and the member certificate allows, a second injection can be approved. The second sacroiliac joint injection must be given at least one week after the previous injection. If a limit is not specified in the member s certificate of coverage, a total of two (2) sacroiliac joint injections (including intra-articular steroid injections, and periarticular injections), regardless of location (left or right), whether diagnostic or therapeutic, may be approved in a year*. Note that bilateral injections will count as 2 injections. Page 2 of 7
Fluoroscopic guidance is required for sacroiliac joint injections. 2. Coccyx injections are considered medically necessary if both of the following conditions are met. A. Chronic coccyx pain (at least 3 months in duration) and B. Symptoms that have failed to respond to a three-month trial of more conservative therapies including anti-inflammatory medications (or other analgesic medication if the anti-inflammatory medication is contraindicated) used on a regular basis; donut cushions; and physical and/or chiropractic therapy after the current episode of symptoms. If the above criteria are met, allow an initial coccyx injection. If the individual has experienced a reduction in pain symptoms of at least 50% for at least two weeks following the initial coccyx injection, a second injection can be approved. The second coccyx injection must be given at least one month after the previous injection. If a limit is not specified in the member s certificate of coverage, a maximum of two coccyx injections in a twelve month period is considered medically necessary. There must be a reduction in pain symptoms of at least 50% for at least two weeks following the previous coccyx injection. 3. Sacroiliac joint fusion (arthrodesis) procedures are considered medically necessary: A. As an adjunct to sacrectomy procedures related to tumors involving the sacrum B. As adjunct to surgical treatment of SI joint infections C. For treatment of severe trauma (e.g. pelvic ring fracture) D. During surgical procedures such as correction of scoliosis extending to the ileum Limitations of Coverage: A. Review contract and endorsements for exclusions and prior authorization or benefit requirements. B. If used for a condition/diagnosis other than is listed in the Indications of Coverage, deny as experimental or investigative. C. If used for a condition/diagnosis that is listed in the Indications of Coverage, but the criteria are not met, deny as not medically necessary. Page 3 of 7
D. If the previous sacroiliac joint injection OR coccyx injection was not effective (symptoms reduced by at least 50 percent), a subsequent injection is not medically necessary. E. A second sacroiliac joint injection provided less than one week after the initial injection is considered not medically necessary. F. A second coccyx injection provided less than one month after the initial injection is considered not medically necessary G. More than two (2) sacroiliac joint injections (including intra-articular steroid injections and periarticular injections) regardless of location (left or right) whether diagnostic or therapeutic, in one year* are considered not medically necessary. Note that bilateral injections will count as 2 injections H. Sacroiliac joint injections provided without the use of fluoroscopic guidance are not current standard medical practice and would be considered not medically necessary. Performing a sacroiliac joint arthrogram in conjunction with a sacroiliac joint injection is considered not medically necessary unless the joint is being evaluated for damage due to trauma. I. Nerve blocks (e,g, sacral medial branch blocks and/or lateral branch blocks) for diagnosing and/or treating sacroiliac joint pain or pain resulting from SI joint derangement / dysfunction are considered experimental / investigational J. Sacroiliac joint ablation (includes water cooled and pulsed RFA), sacral branch neuroablations (e.g. sacral medical branch neuroablation) or fusion/ arthrodesis are considered experimental or investigational for management of back/buttocks pain or SI joint dysfunction. Diagnostic sacroiliac joint injections done in preparation for SI joint ablation or fusion/ arthrodesis are not covered as they would be related to the non-covered ablation/ fusion service. K. Injection of a caustic agent such as phenol or alcohol into a sacroiliac joint is considered experimental or investigative. L. Sacroplasty is considered experimental/investigative/non-covered. (See also Noncovered Services Policy and Percutaneous Vertebroplasty, Kyphoplasty, Sacroplasty Policy) M. If other pain management services (e.g. Lumbar Epidural Spine Injections, facet joint injections, medial branch nerve blocks, lumbar sympathetic blocks, surgery) are provided on the same date of service as the sacroiliac joint injection, the other injection is considered not medically necessary Page 4 of 7
Documentation Required: History and physical, office notes and relevant reports of prior procedures Rationale: Recent studies have suggested that the sacroiliac joint is a significant source of low back pain. Although evidence is limited due to the low number of randomized controlled clinical trials, inconsistencies between trials, and flaws in design and conduct of studies documenting the effectiveness of sacroiliac joint injections for the management of low back pain, these injections have become widely used. There is minimal peer-reviewed literature regarding the effectiveness of ablation of the sacroiliac joint or nerves. Published reviews of the existing literature, and 2 merged clinical trials revealed insufficient evidence of the efficacy, superiority over conservative treatments, or long term outcomes of SI ablation or fusion procedures in the treatment of back pain. Conservative treatment is successful in 90% of coccydynia cases and many resolve without medical treatment. Evidence-based literature supporting the effectiveness of interventional procedures is lacking and although advocated by many specialists, clear consensus on the best site of injection has not been reached. References: 1. Boswell MV, Trescot AM, Datta S, Schultz DM, Hansen HC, Abdi S, Sehgal N, Shah RV, Singh V, Benyamin RM, Patel VB, Buenaventura RM, Colson JD, Cordner HJ, Epter RS, Jasper JF, Dunbar EE, Atluri SL, Bowman RC, Deer TR, Swicegood JR, Staats PS, Smith HS, Burton AW, Kloth DS, Giordano J, Manchikanti L. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Phys 2007 Jan;10(1):7-111. Available at: www.asipp.org/documents/guidelines2007.pdf. Accessed: 3 Nov 12 2. Foley BS, Buschbacher RM. Sacroiliac joint pain: anatomy, biomechanics, diagnosis, and treatment. Am J Phys Med Rehabil. 2006 Dec; 85(12):997-1006. 3. Hansen HC, McKenzie-Brown AM, Cohen SP, Swicegood JR, Colson JD, Manchikanti L. Sacroiliac joint interventions: a systematic review. Pain Physician. 2007 Jan; 10(1):165-84. Available at: www.painphysicianjournal.com/2007/january/2007;10;165-184.pdf. Accessed: 11 Jul 10. 4. Manchikanti L, Boswell MV, Singh V, Benyamin RM, Fellows B, Abdi S, Page 5 of 7
Buenaventura RM, Conn A, Datta S, Derby R, Falco FJE, Erhart S, Diwan S, Hayek SM, Helm II J, Parr AT, Schultz DM, Smith HS, Wolfer LR, and Hirsch JA. Comprehensive Evidence-Based Guidelines for Interventional Techniques in the Management of Chronic Spinal Pain. Pain Physician 2009; 12: 699-802. Available at: www.asipp.org/documents/comprehensiveevidence- BasedGuidelinesforInterventionalTechniquesintheManagementofChronicSpin.pd. Accessed: 2 Nov 12. 5. Rupert M, Lee M, Manchikanti L, et.al. Evaluation of sacroiliac joint interventions: a systematic appraisal of the literature. Pain Physician. 2009 Mar- Apr;12(2):399-418. 6. Brox J, Nygaard O, Holm I, et.al. Four-year followup of surgical versus nonsurgical therapy for chronic low back pain. Ann Rheum Dis 2010 Sep; 69(9):1643-8 full Text available at: http://www.ncbi.nlm.nih.gov/pmc/articles/pmc2938881/ Accessed 3/Dec 13 7. Manchikanti L, Abdi S, Alturi S, et al. An update of Comprehensive evidencebased guidelines for interventional techniques in the management of chronic spine pain. Part II: guidance and recommendations. Pain Physician, 2013 Apr;16 (2Suppl):s49-s283Available at: http://www.guideline.gov/content.aspx?id=45379 Accessed 27 Aug, 14 8. Hayes Search and Summary Sacroiliac Joint Injections with Corticosteroids for Treatment of Chronic Low Back Pain. July 31, 2014 9. Hayes Medical Technology Directory. Radiofrequency Ablation for Sacroiliac Joint Pain. Publication Date: August 21, 2012. Annual Review: June 11, 2015. 10. Hayes Search and Summary. Lateral branch nerve block for diagnosis and treatment of SI joint pain. June 26, 2014 11. Hayes News-Government. FDA warns of Cortisone Injections. April 28, 2014. 12. US Food and Drug Administration (FDA:) Epidural Corticosteroid Injection: Drug Safety Communication - Risk of Rare But Serious Neurologic Problems (Including methylprednisolone, hydrocortisone, triamcinolone, betamethasone, and dexamethasone)posted 04/23/2014. Available at http://www.fda.gov/safety/medwatch/safetyinformation/safetyalertsforhuman MedicalProducts/ucm394530.htm 13. Chou R, Atlas S, Stano S et.al. Nonsurgical Interventional Therapies for Low Back Pain. A review of the Evidence for an American Pain Society Clinical Practice Guideline. Spine 2009 34(10), pp.1078-1093 Page 6 of 7
14. Up to Date. Coccydynia (coccygodynia). Literature review current through: June 2015. This topic last updated: July 11, 2013. 15. Hayes Technology Brief. Sacroiliac Joint Injections with Corticosteroids for Treatment of Chronic Low Back Pain. Publication Date: October 9, 2014. Annual Review: July 24, 2015. 16. Hayes Search and Summary. Therapeutic Injection for Treatment of Coccydynia. Aug 6, 2015 17. Patel R, Appannagari A, Whang PG. Coccydynia. Curr Rev Musculoskelet Med. 2008;1(3-4):223-226 Approved by the Medical Director Page 7 of 7