Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sacroiliac joint dysfunction

Treatment: pain Injection: 64451 x 1

The insurer denied coverage for pain Injection: 64451 x 1

The denial is upheld

According to the documentation provided, this is a geriatric patient with peripheral neuropathy, hypertension, hyperlipidemia, lumbar laminectomy, and right lower back pain. The pain is over the right lower back without radiation or radicular symptoms, present at a low level for the last 4-5 years, consistent with sacroiliac joint (SIJ) dysfunction. Physical exam reveals tenderness to palpation over the right SIJ. Positive right flexion, abduction, and external rotation (FABER)/Patricks, thigh thrust, Gaenslen's. The ability to stand or walk is limited secondary to pain. Pain is alleviated by resting and oxycodone. Magnetic Resonance Imaging (MRI) shows degenerative disc disease and facet arthropathy with canal and foraminal stenosis. The patient has been treated in the past with SIJ injections (SIJI) with moderate 1 week relief, right Lumbar (L)3-5 Medial Branch Block (MBB), L5-Sacral (S)3 LBB, and right L3-5 radiofrequency ablation (RFA). Failed rest and behavior modifications, intractable to medications, opioid pain medications for > 6 weeks. There is no mention in the medical record of failed additional conservative therapy. Conservative treatment of SIJ pain may include physiotherapy, manipulative therapy or anti-inflammatory agents. Patients who fail conservative treatment may require periarticular or intra-articular corticosteroid for pain relief. 

According to the Centers for Medicare and Medicaid Services (CMS) guidelines (2) (Sacroiliac Joint Injections and Procedures - DL39402. Sacroiliac joint injections (SIJI) will be considered medically reasonable and necessary when all the following requirements are met: 1) Moderate to severe lower back pain (LBP) primarily experienced over the anatomical location of the SI joints between the upper level of the iliac crests and the gluteal fold, AND 2) LBP duration of at least 3 months, AND 3) LBP below L5 without radiculopathy, AND 4) Clinical findings and/or imaging studies do not suggest any other diagnosed or obvious cause of the lumbosacral pain (such as central spinal stenosis with neurogenic claudication/myelopathy, foraminal stenosis or disc herniation with concordant radicular pain/radiculopathy, infection, tumor, fracture, pseudoarthrosis, or pain related to spinal instrumentation), AND 5) At least 3 positive findings with provocative maneuvers: FABER, Gaenslen, Thigh Thrust or Posterior Shear, sacroiliac (SI) Compression, SI Distraction and Yeoman Tests, 3, 4 AND 6) LBP persists despite a minimum of 4 weeks of conservative therapies.

Based on this information, outpatient procedure 64451 x 1 is not considered medically necessary for this patient at this time. While this patient does meet the first 5 CMS requirements for SIJI to be medically reasonable and necessary, there is insufficient evidence in the medical record of failed conservative therapies such as physiotherapy or manipulative therapy. Furthermore, UpToDate does not support the routine use of SIJ injections for pain relief. They note the absence of any randomized trial showing benefit vs sham procedure. Also, prior SIJ injection provided only 1 week of pain relief. Repeat SIJI is not medically necessary.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for pain Injection: 64451 x 1 is not substantiated.