GENERAL INFORMATION

It is an expectation that all patients receive care/services from a licensed clinician.  All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided.  If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted.

Special Note
Any injection performed at least two years from prior injections in the same region will be considered a new episode of care and the INITIAL injection requirements must be met for approval. Events such as surgery on the same spinal region or any new pathology would also prompt a new episode of care.

Indications for Sacroiliac Joint Injections (Intraarticular or ligamentous injections only)

For the treatment of sacroiliac joint (SIJ) pain ALL of the following must be met:

• Primarily axial low back pain (below level of L5) which may radiate to the groin or lower extremity
• Pain causing functional disability or average pain level of ≥ 6 on a scale of 0 to 10 related to the requested spinal region
• A cluster of any three (3) of the following positive provocation exam findings to suggest the diagnosis ^5,6,7:
  • Pelvic (SI) distraction test
  • Pelvic (SI) compression test
  • Sacral Thrust test
  • FABER (Patrick’s test)
  • Posterior shear test
  • Yeoman’s test
  • Gaenslen’s test
  • Thigh Thrust test
• Duration of pain of at least 3 months
• Failure to respond to non-operative conservative treatment targeting the requested spinal region for a minimum of 6 weeks in the last 6 months unless the medical reason this treatment cannot be done is clearly documented;
  • OR details of active engagement in ongoing non-operative conservative treatment if the individual has had prior spinal injections in the same region

ALL of the following must be met:

• The individual has experienced ≥ 3 months of low back pain
• Age of onset < 45 years
• Comprehensive pain management program is in place including physical therapy, home exercise, patient education, psychosocial support, and/or oral medication
• Prior history of evidence of sacroiliitis on imaging (i.e., active inflammation on magnetic resonance imaging [MRI] or definite radiographic sacroiliitis grade 2-4 bilaterally or grade 3-4 unilaterally)
• 1 or more spondyloarthropathy features: 
  • Inflammatory back pain evidence with at least 4 of the following criteria present ⁹:
    • Age at onset < 40 years
    • Insidious onset
    • Improvement with exercise
    • No improvement with rest
    • Pain at night (with improvement upon getting up)
  • Arthritis
  • Enthesitis of the heel (irritability of muscles, tendons, or ligaments where they enter the bone) 
  • Uveitis (inflammation of the uvea, the middle layer of the eye)
  • Dactylitis (inflammation of a finger or toe)
  • Psoriasis
  • Crohn’s/colitis
  • Good response to NSAIDs
  • Family history of spondyloarthropathy
  • Positive testing for HLA-B27 
  • Elevated C-reactive protein (CRP)

• The sacroiliac joint is commonly identified under image guidance by Fluoroscopy or Computed tomography (CT). CT is less effective than Fluoroscopy regarding observing of the escape of the injectate to the adjacent structures and cannot rule out concurrent intravascular flow. With proper use by skilled interventional pain physicians with ultrasound experience, the use of ultrasound guidance is similar to CT or Fluoroscopy but can have a lower accuracy of needle placement. 
• Ultrasound guidance can be an effective alternative if fluoroscopy or CT guided techniques are contraindicated or when radiation exposure is problematic; however, individual patient factors such as poor visualization due to deeper tissue layers (e.g., increased Body Mass Index (BMI) may contribute to substandard image resolution).

NOTE: ALL procedures must be performed under imaging guidance

For diagnostic purposes, all the following must be met:

• The sacroiliac joint injection is an image-guided, contrast-enhanced intra-articular injection
• At least 75% pain relief for the expected duration of the anesthetic after each diagnostic injection
• After the diagnostic relief period, the individual continues to have pain causing functional disability or average pain level ≥ 6 on a scale of 0 to 10 related to the requested spinal region.
• No more than two diagnostic injections per diagnostic phase
• Documentation of a pre-operative evaluation and plan for SIJ surgery

Sacroiliac joint injections may be repeated only as medically necessary. Each sacroiliac joint injection requires an authorization, and the following criteria must be met for repeat injections:

• Up to 2 sacroiliac joint injections may be performed in the initial treatment phase, no sooner than 2 weeks apart, provided that at least 50% pain relief or significant documented functional improvement is obtained

• Sacroiliac joint injections may only be repeated after the initial treatment phase if the individual has had at least 50% pain relief or significant documented functional improvement for a minimum of 2 months before each therapeutic injection
• The individual continues to have pain causing functional disability or average pain level ≥ 6 on a scale of 0 to 10 related to the requested spinal region
• The individual is engaged in ongoing active conservative treatment unless the medical reason this treatment cannot be done is clearly documented
• For individuals that have received other interventional pain injections in the lumbar/sacral region (e.g., epidural steroid injection or facet joint injection) since the last SIJ injection, at least one repeat positive provocative exam finding is required (pelvic (SI) distraction test, pelvic (SI) compression test, sacral thrust test, FABER (Patrick’s test), posterior shear test, Yeoman’s test, Gaenslen’s test, or thigh thrust)
• A maximum of 4 sacroiliac joint injections may be performed in a 12-month period per region in the therapeutic phase

These requests are excluded from consideration under this guideline:

• Sacral lateral branch blocks (S1, S2, S3)
• Radiofrequency denervation of the sacroiliac joint

• Absolute contraindications:
  • Active systemic or spinal infection
  • Skin infection at the site of needle puncture
  • Local malignancy
  • Septic joint
• Relative contraindications:
  • Coagulopathy
  • Pregnancy
  • Uncontrollable Diabetes
  • Current and uninterrupted use of blood-thinning medication

Low back pain originating from the SIJ can result from inflammatory conditions such as sacroiliitis, spondyloarthropathy (e.g., ankylosing spondylitis, rheumatoid spondylitis), or from postsurgical or traumatic injury, degeneration (wear and tear), or pregnancy. SIJ pain most often occurs in the buttocks and lower back and may radiate down through the buttocks and the leg. Physical examination and radiographic techniques may confirm a diagnosis related to spondyloarthropathy. Physical examination, including provocative maneuvers to elicit pain response, and controlled SIJ injections can help diagnose noninflammatory pain arising from the SIJ.

Risks associated with SIJ dysfunction ^3,4:

• Gait abnormalities
• Scoliosis
• Leg-length discrepancies
• Inflammatory spondyloarthropathies, including ankylosing spondylitis
• Previous spine surgeries
• Connective tissue disorders (e.g., Ehlers–Danlos syndrome)
• Pregnancy associated with ligamentous laxity and hypermobility
• Obesity

Spinal injections for the treatment of SIJ pain syndrome are typically performed as one part of a comprehensive treatment program, but initial treatment usually includes over-the-counter analgesics, home exercise program to improve or maintain spinal mobility, and therapy sessions with a physical therapist involving range-of-motion, stretching, and strengthening exercises.

Sacroiliac joint injections are typically used for the following conditions:

• Sacroiliac joint (SIJ) syndrome may be caused by various events, including pain secondary to postsurgical or traumatic injury, degeneration (wear and tear), or pregnancy.
• Diagnostic SIJ injections are used to determine if the SIJ pain originates with the SIJ. Diagnostic blocks can reveal (or fail to reveal) that the source of pain is originating from the SIJ; appropriate treatment plan can be developed.
• Therapeutic SIJ injections used to treat SIJ pain once it has been determined that the SIJ is the origin of the pain. A therapeutic injection typically includes a corticosteroid and a local anesthetic that can be injected directly into the joint (intra-articular) or into the tissues surrounding the joint (periarticular).
• Spondyloarthropathy (also known as spondyloarthritis) is the name for a family of rheumatic diseases that cause arthritis. Sacroiliitis is a key indicator of spondyloarthritis and is diagnosed with imaging. Individuals with spondyloarthropathy are generally managed by rheumatologists. 

The indications for coverage for the treatment of spondyloarthropathy have been established through criteria developed by the Assessment of SpondyloArthritis International Society (ASAS) for the classification of axial spondyloarthritis. ¹¹ They are in keeping with the benefit guidelines developed by the Centers for Medicare & Medicaid Services (CMS). ¹²

Telehealth visits have become routine in modern medical practice.  However, sacroiliac joint injections cannot be performed via telehealth encounters. Individuals who can schedule an in- person encounter for injection are expected to also schedule an in-person encounter for provocative physical examination, prior to injection, in order to document the medical necessity of the joint injection.

It is generally considered NOT MEDICALLY NECESSARY to perform multiple interventional pain procedures on the same date of service. Documentation of a medical reason to perform injections in different regions on the same day can be provided and will be considered on a case-by-case basis (e.g., holding anticoagulation therapy on two separate dates creates undue risk for the patient).

• Documentation of an exercise prescription/plan provided by a physician, physical therapist, or chiropractor

AND

• Follow-up documentation regarding completion of HEP after the required 6-week timeframe or inability to complete HEP due to a documented medical reason (e.g., increased pain or inability to physically perform exercises).

References

1. Manchikanti L, Kaye A D, Soin A, Albers S L, Beall D et al. Comprehensive Evidence-Based Guidelines for Facet Joint Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines Facet Joint Interventions 2020 Guidelines. Pain physician. 2020; 23: S1-S127.

2. Wu L, Tafti D, Varacallo M. Sacroiliac Joint Injection. StatPearls [Internet]. 2023; https://www.ncbi.nlm.nih.gov/books/NBK513245/.

3. Sayed D, Deer T R, Tieppo Francio V, Lam C M, Sochacki K et al. American Society of Pain and Neuroscience Best Practice (ASPN) Guideline for the Treatment of Sacroiliac Disorders. Journal of pain research. 2024; 17: 1601-1638.

4. Sayed D, Grider J, Strand N, Hagedorn J M, Falowski S et al. The American Society of Pain and Neuroscience (ASPN) Evidence-Based Clinical Guideline of Interventional Treatments for Low Back Pain. Journal of pain research. 2022; 15: 3729-3832.

5. Telli H, Telli S, Topal M. The Validity and Reliability of Provocation Tests in the Diagnosis of Sacroiliac Joint Dysfunction. Pain physician. 2018; 21: E367-E376.

6. MacVicar J, Kreiner D S, Duszynski B, Kennedy D J. Appropriate Use Criteria for Fluoroscopically Guided Diagnostic and Therapeutic Sacroiliac Interventions: Results from the Spine Intervention Society Convened Multispecialty Collaborative. Pain medicine (Malden, Mass.). 2017; 18: 2081-2095.

7. Saueressig T, Owen P J, Diemer F, Zebisch J, Belavy D L. Diagnostic Accuracy of Clusters of Pain Provocation Tests for Detecting Sacroiliac Joint Pain: Systematic Review With Meta-analysis. The Journal of orthopaedic and sports physical therapy. 2021; 51: 422-431.

8. National Institute for Health and Care Excellence. Spondyloarthritis in over 16s: diagnosis and management. NICE. 2017; https://www.nice.org.uk/guidance/ng65/resources/spondyloarthritis-in-over-16s-diagnosis-and-management-pdf-1837575441349.

9. Sieper J, van der Heijde D, Landewé R, Brandt J, Burgos-Vagas R et al. New criteria for inflammatory back pain in patients with chronic back pain: a real patient exercise by experts from the Assessment of SpondyloArthritis international Society (ASAS). Annals of the rheumatic diseases. 2009; 68: 784-8.

10. Washington State Health Care Authority. Health Technology Clinical Committee Coverage Topic 20160318B – Spinal Injections. 2016; https://www.hca.wa.gov/assets/program/spinal_injections-rr_final_findings_decision_060216.pdf.

11. Sieper J, Rudwaleit M, Baraliakos X, Brandt J, Braun J et al. The Assessment of SpondyloArthritis international Society (ASAS) handbook: a guide to assess spondyloarthritis. Annals of the rheumatic diseases. 2009; 68 Suppl 2: ii1-44.

12. Centers for Medicare & Medicaid Services. Sacroiliac Joint Injections and Procedures. 2024; Accessed: 30-Aug-2024. https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=59246&amp;ver=17&amp;keyword=sacroiliac&amp;keywordType=starts&amp;areaId=all&amp;docType=NCA,CAL,NCD,MEDCAC,TA,MCD,6,3,5,1,F,P&amp;contractOption=all&amp;sortBy=relevance&amp;bc=1.

13. Qaseem A, Wilt T J, McLean R M, Forciea M A, Denberg T D et al. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Annals of internal medicine. 2017; 166: 514-530.

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

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