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Diagnosis and Treatment of Sacroiliac Joint Pain

Arthrography of the sacroiliac joint (SIJ) is considered investigational.Injection of anesthetic for diagnosing SIJ pain may be considered medically necessary when the following criteria have been met:

Pain has failed to respond to 3 months of conservative management, which may consist of therapies such as nonsteroidal anti-inflammatory medications, acetaminophen, manipulation, physical therapy, and a home exercise program; and

Dual (controlled) diagnostic blocks with 2 anesthetic agents with differing duration of action are used; and

The injections are performed under imaging guidance.

Injection of corticosteroid may be considered medically necessary for the treatment of SIJ pain when the following criteria have been met:

Pain has failed to respond to 3 months of conservative management, which may consist of therapies such as nonsteroidal anti-inflammatory medications, acetaminophen, manipulation, physical therapy, and a home exercise program; and

The injection is performed under imaging guidance; and

No more than 3 injections are given in 1 year.

Minimally invasive fixation/fusion of the SIJ using transiliac placement of a titanium triangular implant (eg, iFuse) may be considered medically necessary when ALL of the following criteria have been met:

Pain is at least 5 on a 0 to 10 rating scale that impacts quality of life or limits activities of daily living; and

There is an absence of generalized pain behavior (eg, somatoform disorder) or generalized pain disorders (eg, fibromyalgia); and

Patients have undergone and failed a minimum 6 months of intensive nonoperative treatment that must include medication optimization, activity modification, bracing, and active therapeutic exercise targeted at the lumbar spine, pelvis, SIJ, and hip, including a home exercise program; and

Pain is caudal to the lumbar spine (L5 vertebra), localized over the posterior SIJ, and consistent with SIJ pain; and

A thorough physical examination demonstrates localized tenderness with palpation over the sacral sulcus (Fortin’s point) in the absence of tenderness of similar severity elsewhere; and

There is a positive response to a cluster of 3 provocative tests (eg, thigh thrust test, compression test, Gaenslen sign, distraction test, Patrick test, posterior provocation test); and

Diagnostic imaging studies include ALL of the following:

Imaging (plain radiographs and computed tomography or magnetic resonance imaging) of the SIJ excludes the presence of destructive lesions (eg, tumor, infection) or inflammatory arthropathy of the SIJ; and

Imaging of the pelvis (anteroposterior plain radiograph) rules out concomitant hip pathology; and

Imaging of the lumbar spine (computed tomography or magnetic resonance imaging) is performed to rule out neural compression or other degenerative condition that can be causing low back or buttock pain; and

Imaging of the SIJ indicates evidence of injury and/or degeneration; and

There is at least a 75% reduction in pain for the expected duration of the anesthetic used following an image-guided, contrast-enhanced intra-articular SIJ injection on 2 separate occasions; and

A trial of a therapeutic SIJ injection (ie, corticosteroid injection) has been performed at least once.

Fixation/fusion of the SIJ for the treatment of back pain presumed to originate from the SIJ is considered investigational under all other conditions and with any other devices not listed above.

Radiofrequency denervation of the SIJ is considered investigational.

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