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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-20000-21

Original Effective Date: 11/15/02

Reviewed: 05/28/15

Revised: 11/01/15

Subject: Sacroiliac Joint Injections

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

The sacroiliac (SI) joint connects the sacrum with the pelvis. The SI joint lies between the sacrum and the ilium, and functions more for stability than for movement. Similar to other structures in the spine, it is assumed that the sacroiliac joint may be a source of low back pain. The sacroiliac joint transmits all the forces of the upper body to the pelvis and legs. The joint’s stability is maintained in part by several large ligaments and muscle groups. Dysfunctions of the sacroiliac joint may be described as sacral, iliac, pubic and sacroiliac joint pain. They are typically without consistent, demonstrable radiographic, or laboratory findings, and most commonly exist in the setting of morphologically normal joints. Pain may arise in the joint itself or in the related muscles and ligaments. Pain may be felt in the lower back or may radiate to one or both hips and/or one or both legs. Clinical tests for sacroiliac joint pain may include various movement tests, palpation to detect tenderness, and pain descriptions by the individual. Conservative treatment for sacroiliac joint dysfunction generally centers on restoring motion in the joint and may include:

• Medications

• Physical therapy

• Chiropractic or osteopathic manipulation

• Sacroiliac joint injections.

Sacroiliac joint injections are divided into two phases, the diagnostic phase and the therapeutic phase. In the diagnostic phase, an injection is given and if there is pain relief (positive block), additional injections are given as part of the therapeutic phase. A second injection may be needed in the diagnostic phase. If there is no pain relief after the diagnostic injection (s) (negative block), the therapy is not continued.

Sacroiliac joint injections are expected to be given at intervals no sooner than every week during a diagnostic phase and no sooner than every eight (8) weeks during the therapeutic phase.

POSITION STATEMENT:

 

Certificate of Medical Necessity

Submit a completed Certificate of Medical Necessity (CMN) along with your request to expedite the medical review process.

1. Click the link Sacroiliac Joint Injections - Certificate of Medical Necessity (MS Word) to open the form.

2. Complete all fields on the form thoroughly.

3. Print and submit a copy of the form with your request.

Note: Florida Blue regularly updates CMNs. Ensure you are using the most current copy of a CMN before submitting to Florida Blue. For a complete list of available CMNs, visit the Certificates of Medical Necessity page.

Sacroiliac joint injection performed under fluoroscopy or with arthrography meets the definition of medical necessity when ALL the following criteria are met:

Sacroiliac joint injections do not meet the definition of medical necessity if medical documentation indicates the injection procedures are not effective.

Sacroiliac joint injection performed with ultrasound guidance is considered experimental or investigational. There is insufficient evidence to support conclusions regarding effects on net health outcomes.

NOTE: It is not expected that epidural blocks, multiple facet joint injections, sacroiliac joint injections, and sympathetic nerve blocks in any and all combinations would be administered to the same individual on the same day. If the first procedure used to treat the presumptive diagnosis fails to produce improvement and rules out that possibility, then it may be appropriate to proceed to the next logical treatment.

BILLING/CODING INFORMATION:

CPT Coding:

27096

Injection procedure for sacroiliac joint, anesthetic/ steroid, with image guidance (fluoroscopy or CT) including arthrography when performed

HCPCS Coding:

G0259

Injection procedure for sacroiliac joint; arthrography

G0260

Injection procedure for sacroiliac joint; provision of anesthetic, steroid AND/OR other therapeutic agent, with or without arthrography

ICD-10 Diagnosis Codes That Support Medical Necessity: (Effective 10/01/15)

M12.551 – M12.559

Traumatic arthropathy, hip

M12.9

Arthropathy, unspecified

M13.0

Polyarthritis, unspecified

M16.0 – M16.9

Osteoarthritis of hip

M16.7

Other unilateral secondary osteoarthritis of hip

M16.9

Osteoarthritis of hip, unspecified

M25.50

Pain in unspecified joint

M25.551 – M25.559

Pain in hip

M25.751 – M25.759

Osteophyte,hip

M40.37

Flatback syndrome, lumbosacral region

M43.27

Fusion of spine, lumbosacral region

M43.28

Fusion of spine, sacral and sacrococcygeal region

M45.0 – M45.9

Ankylosing spondylitis

M46.1

Sacroiliitis, not elsewhere classified

M47.817

Spondylosis without myelopathy or radiculopathy, lumbosacral region

M48.06

Spinal stenosis, lumbar region

M48.07

Spinal stenosis, lumbosacral region

M51.15 – M51.17

Intervertebral disc disorders with radiculopathy

M53.2x7

Spinal instabilities, lumbosacral region

M53.2x8

Spinal instabilities, sacral and sacrococcygeal region

M53.3

Sacrococcygeal disorders, not elsewhere classified

M54.14 – M54.17

Radiculopathy, thoracic, thoracolumbar, lumbar and lumbosacral region

M54.30 – M54.32

Sciatica

M54.40 – M54.42

Lumbago with sciatica

M54.5

Low back pain

M70.60 – M70.62

Trochanteric bursitis

M70.70 – M70.72

Other bursitis of hip

M76.10 – M76.12

Psoas tendinitis

M76.20 – M76.22

Iliac crest spur

M76.30 – M76.32

Iliotibial band syndrome

M99.04

Segmental and somatic dysfunction of sacral region

M99.05

Segmental and somatic dysfunction of pelvic region

Q76.2

Congenital spondylolisthesis

REIMBURSEMENT INFORMATION:

Total number of sacroiliac joint injections is limited to three (3) injections per sacroiliac joint in six (6) months.

NOTE: Services in excess of the limitations shown above are subject to medical review of documentation for determination of medical necessity. The following information may be required documentation to support medical necessity: physician history and physical, radiology study reports, physician progress notes, with documentation of conservative treatment, treatment plan including narrative, and physician operative report.

LOINC Codes:

Documentation Table

LOINC Codes

LOINC Time Frame Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Attending physician progress notes

18741-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Radiology report

18726-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physician operative report

28573-4

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Treatment plan, plan of treatment

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physical therapy initial assessment

18735-1

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physical therapy progress note

11508-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Current, discharge, or administered medications

34483-8

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage Products: The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Sacroiliac Joint Injection (L29274) located at fcso.com.

DEFINITIONS:

Arthrography: a diagnostic study of the joint structures. X-ray contrast is injected, as the dye disperses, the radiologist documents whether the dye is contained or is leaking (indicates the stability and integrity of the joint and reveals cartilage tears and other injuries).

RELATED GUIDELINES:

None applicable

OTHER:

None applicable

REFERENCES:

  1. AHRQ National Guideline Clearinghouse. Guideline Summary NGC-8515: Hip & pelvis (acute & chronic). Encinitas (CA): Work Loss Data Institute; 2011.
  2. AHRQ National Guideline Clearinghouse. Guideline Summary NGC-9327: Low back disorders. 3rd ed. Elk Grove Village (IL): American College of Occupational and Environmental Medicine (ACOEM); 2011. p. 333-796.
  3. AHRQ National Guideline Clearinghouse. NGC-9842: 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.
  4. AHRQ National Guideline Clearinghouse. Guideline Summary NGC-10121: Low back - lumbar & thoracic (acute & chronic). Encinitas (CA): Work Loss Data Institute; 2013 Dec 4.
  5. 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. Journal of Pain Research 2012:5 265–269.(Accessed 05/27/14).
  6. Ashman B, Norvell DC, Hermsmeyer JT. Chronic sacroiliac joint pain: fusion versus denervation as treatment options. Evid Based Spine Care J. 2010 Dec;1(3):35-44.
  7. Blue Cross Blue Shield Association. Medical Policy Reference Manual. 6.01.23 Diagnosis and Treatment of Sacroiliac Joint Pain. April 2015.
  8. 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; American Society of Interventional Pain Physicians. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician. 2007 Jan; 10(1): 7-111.
  9. Buchanan P, Mehta A, Gerstman B. Interventional Treatments for Sacroiliac Joint Pain. Current physical medicine and rehabilitation reports 2.1 (2014): 66-69.
  10. Chou R, Huffman LH. Evidence Review: Guideline for the Evaluation and Management of Low Back Pain. American Pain Society, Publisher; Glenview, IL. Accessed at http://www.americanpainsociety.org/ on 05/30/13.
  11. Chou R, Qaseem A, Snow V, Casey, D, Cross, Jr JT, Shekelle P, Owens DK. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Ann Intern Med October 2, 2007 vol. 147 no. 7 478-491. (Accessed 05/30/13).
  12. Chou, R, Loeser, J, Owens, D, Rosenquist, R, Atlas, S, Baisden, J, Carragee, E, Grabois, M, Murphy, D, Resnick, D, Stanos, S, Shaffer, W, Wall, E. Interventional Therapies, Surgery, and Interdisciplinary Rehabilitation for Low Back Pain: An Evidence-Based Clinical Practice Guideline From the American Pain Society. Spine: 1 May 2009 – Volume 34 – Issue 10 – pp 1066-1077.
  13. ClinicalTrials.gov. Unguided Sacroiliac Injection: Effect on Refractory Buttock Pain in Patients With Spondyloarthropathies. NCT 00829543. Tabriz Medical University, Rheumatology Department. Islamic Republic of Iran. February 2009. (Accessed 05/27/14).
  14. ClinicalTrials.gov. Effect of Sedation on Diagnostic Injections. NCT01472835. Johns Hopkins University. April 2012.
  15. ClinicalTrials.gov. NCT01719081: Sacroiliac Joint Injection: Comparison of Xray Versus Ultrasound. University Health Network, Toronto; October 2012. (Accessed 05/27/14).
  16. ClinicalTrials.gov. Fluoroscopically-guided Versus Landmark-guided Sacroiliac Joint Injections. NCT02096653. Centers for Rehabilitation Sciences Research: Walter Reed National Military Medical Center. March 2014.
  17. Cui Y, Xiao Z, Shuxia W, Zhenjun Z, Hengguo Z, Liangyi F, Weicheng G, Li L, Guangfeng Z, Yunzhen S, Guangfu D. Computed tomography guided intra-articular injection of etanercept in the sacroiliac joint is an effective mode of treatment of ankylosing spondylitis. Scand J Rheumatol. 2010 May;39(3):229-32.
  18. Datta S, Derby R, Falco FJE, Erhart S, Diwan S, Hayek SM, Helm II S, Parr AT, Schultz DM, Smith HS, Wolfer LR, Hirsch JA. Comprehensive Evidence-Based Guidelines for Interventional Techniques in the Management of Chronic Spinal Pain. Pain Physician 2009; 12:699-802.
  19. ECRI Health Technology Assessment Information Services. Custom Hotline Response. Sacroiliac Joint Injections for Back and Lower Extremity Pain. Updated 06/05/07.
  20. Florida Medicare Part B Local Coverage Determination. L29274 Sacroiliac Joint Injection, 02/02/09. (Revised 01/01/12).
  21. Gupta S. Double Needle Technique: An Alternative Method for Performing Difficult Sacroiliac Joint Injections. Pain Physician 2011; 14:281-284. (Accessed 05/27/14).
  22. Hansen H, Manchikanti L, MD2, Simopoulos TT, Christo PJ, Gupta S, Smith HS, Hameed H, Cohen, SP. Systematic Evaluation of the Therapeutic Effectiveness of Sacroiliac Joint Interventions. Pain Physician 2012; 15:E247-E278.
  23. Hartung W, Ross CJ, Straub R, Feuerbach S, Schölmerich J, Fleck M, Herold T. Ultrasound-guided sacroiliac joint injection in patients with established sacroiliitis: precise IA injection verified by MRI scanning does not predict clinical outcome. Rheumatology (Oxford). 2010 Aug;49(8):1479-82.
  24. Hayes, Inc. Hayes Search & Summary. Sacroiliac and Ligamentous Injections with Corticosteroids for Treatment of Back and Leg Pain. Lansdale, PA: Hayes, Inc.; May 2007.
  25. Institute for Clinical Systems Improvement (ICSI). Health Care Guideline: Assessment and Management of Chronic Pain. Fifth Edition. November 2011.
  26. InterQual® 2013.2. CP: Procedures (Adult). Sacroiliac (SI) Joint Injection.
  27. InterQual® 2014. CP: Procedures (Adult). Sacroiliac (SI) Joint Injection.
  28. Jee H, Lee JH, Park KD, Ahn J, Park Y. 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.
  29. Klauser A, De Zordo T, Feuchtner G, Sögner P, Schirmer M, Gruber J, Sepp N, Moriggl B. Feasibility of ultrasound-guided sacroiliac joint injection considering sonoanatomic landmarks at two different levels in cadavers and patients. Arthritis Rheum. 2008 Nov 15;59(11):1618-24.
  30. Longo UG, et al. Degenerative changes of the sacroiliac joint after spinal fusion: an evidence-based systematic. British Medical Bulletin 112 (2014): 47-56.
  31. Manchikanti L, et. al. An Update of Comprehensive Evidence-Based Guidelines for Interventional Techniques in Chronic Spinal Pain. Part II: Guidance and Recommendations. Pain Physician 2013; 16:S49-S283.
  32. Manchikanti L, Boswell MV, Singh V, Benyamin RM, Fellows B, Abdi S, Buenaventura RM, Conn A, Datta S, Derby R, Falco FJE, Erhart S, Diwan S, Hayek SM, Helm II S, Parr AT, Schultz DM, Smith HS, Wolfer LR, Hirsch JA. Comprehensive Evidence-Based Guidelines for Interventional Techniques in the Management of Chronic Spinal Pain. Pain Physician 2009; 12:699-802. (Accessed 05/27/14).
  33. Manchikanti, L., Singh, V., Kloth, D. Interventional Pain Management Practice Policies; Sacroiliac Joint Injections. American Society of Interventional Pain Physicians. Accessed 04/08/09.
  34. Manchikanti L, Datta S, Derby R, Wolfer LR, Benyamin RM, Hirsch JA. A Critical Review of the American Pain Society Clinical Practice Guidelines for Interventional Techniques: Part 1. Diagnostic Interventions. Pain Physician 2010; 13:E141-E174.
  35. Manchikanti L, Datta S, Gupta S, Munglani R, Bryce DA, Ward SP, FFPMRCA6 , Benyamin RM, Sharma ML, Helm II S, Fellows B, Hirsch JA. A Critical Review of the American Pain Society Clinical Practice Guidelines for Interventional Techniques: Part 2. Therapeutic Interventions. Pain Physician 2010; 13:E215-E264.
  36. Matthew P. Rupert, MD, MS, Marion Lee, MD, Laxmaiah Manchikanti, MD, Sukdeb Datta, MD, and Steven P. Cohen, MD. Evaluation of Sacroiliac Joint Interventions: A Systematic Appraisal of the Literature. Pain Physician. March/ April 2009. Vol12; 399-418.
  37. Rathmell, J. The Promise of an Effective Treatment for Sacroiliac-related Low Back Pain. Anesthesiology: August 2008 – Volume 109 – Issue 2 – pp 167-168.
  38. Rosenquist RW, Benzon HT, Connis RT, De Leon-Casasola OA, Glass DD, Korevaar WC, Cynwyd B, Mekhail NA, Merrill DG, Nickinovich DG, Rathmell JP, Nai-Mei Sang C, Simon DL, Deer TR. 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: April 2010 – Volume 112 – Issue 4 – pp 810-833. (Accessed 05/30/13).
  39. Sardar K, et al. Sacroiliac joint arthropathy and low back pain. Journal of BSA, 2009; 22(2): 78-83.
  40. Savigny P, Kuntze S, Watson P, Underwood M, Ritchie G , Cotterell M, Hill D, Browne N, Buchanan E, Coffey P, Dixon P, Drummond C, Flanagan M, Greenough,C, Griffiths M, Halliday-Bell J, Hettinga D, Vogel S, Walsh D. Low Back Pain: early management of persistent non-specific low back pain. London: National Collaborating Centre for Primary Care and Royal College of General Practitioners.
  41. Simopoulos TT, Manchikanti L, Singh V, Gupta S, Hameed H, Diwan S, MD6, Cohen SP. A Systematic Evaluation of Prevalence and Diagnostic Accuracy of Sacroiliac Joint Interventions. Pain Physician 2012; 15:E305-E344.
  42. Spiker WR, et. al. Surgical versus injection treatment for injection-confirmed chronic sacroiliac joint pain. Evidence-Based Spine-Care Journal Volume 3/Issue 4 — 2012.
  43. Taljanovic MS, Daffner RH, Weissman BN, Appel M, Arnold E, Bancroft LW, Bennett DL, Blebea JS, Bruno MA, Fries IB, Hayes CW, Kransdorf MJ, Luchs JS, Morrison WB, Palestro CJ, Roberts CC, Stoller DW, Tuite MJ, Ward RJ, Wise JN, Zoga AC, Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria® chronic hip pain. Guideline Summary NGC-8862. American College of Radiology (ACR); 2011.
  44. Yoshihara H. Sacroiliac joint pain after lumbar/lumbosacral fusion: current knowledge. Eur Spine J. 2012 Sep;21(9):1788-96.
  45. Zacchino M, Almolla J, Canepari E, Merico V, Calliada F. Use of ultrasound-magnetic resonance image fusion to guide sacroiliac joint injections: a preliminary assessment. J Ultrasound. 2013 Jul 31;16(3):111-8.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 05/28/15.

GUIDELINE UPDATE INFORMATION:

11/15/02

New Medical Coverage Guideline.

02/15/03

Program Exception added for Medicare & More due to previously being omitted.

05/15/03

Revised Billing & Coding section to include clarification for sacroiliac joint injections; 27096 are considered investigational.

08/15/03

Revised When Services Are Covered and Billing/Coding sections.

07/15/04

Review and revision to guideline consisting of updated references and various changes.

11/15/04

MCG archived per MPCC recommendation.

11/15/07

Review and revision of guideline consisting of updated references and addition of diagnosis codes.

05/15/09

Scheduled review; revise description section to include medical necessity management statement, update position statement to include coverage criteria, update ICD 9 coding by adding 846.0, remove CPT code 73542, remove HCPCS code G0259, and updated reimbursement information. Update references.

01/01/10

Annual HCPCS coding update: revise descriptor for CPT code 77003.

05/15/10

Review with revision to position statement and reimbursement statement consisting of the addition of CPT code 73542 for arthrography.

10/01/10

4th Quarter HCPCS coding update: ICD-9 diagnosis code 724.02 revised; ICD-9 diagnosis code 724.03 added.

10/15/10

Revision; related ICD-10 codes added.

01/01/11

Annual HCPCS coding update. Revised descriptor for code 77003.

04/15/11

Scheduled review; revised description, position statement and reimbursement sections; added Medicare program exception; updated references; reformatted guideline.

07/01/11

Revision; formatting changes.

01/01/12

Annual HCPCS coding update. Revised 27096 and 77003 descriptors. Deleted 73542.

07/15/12

Scheduled review; position statement maintained. Revised description section, CPT coding, ICD9 coding and Medicare Advantage program exception. Updated references. Reformatted guideline.

07/15/13

Scheduled review; position statement maintained. Revised Medicare Advantage program exception.

07/15/14

Scheduled review. Revised position statement and HCPCS coding, Updated references. Reformatted guideline.

06/15/15

Scheduled review. Position Statement maintained. Updated references and reformatted guideline.

10/01/15

Revision; updated ICD9 and ICD10 coding sections.

11/01/15

Revision: ICD-9 Codes deleted.

Date Printed: June 26, 2017: 01:13 AM