Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

The patient is a 43-year-old female who has a history of low back pain. She is status post open reduction and internal fixation of a left femoral neck fracture in 2011, and reported an onset of right SI joint pain that began in 2013. She underwent right SI joint corticosteroid injections on 9/20/16 and 4/19/17. The 6/15/17 lumbar spine magnetic resonance imaging (MRI) documented a small midline disc extrusion at L5/S1 with no canal stenosis or nerve root compression, and was otherwise normal. The 9/19/17 physical therapy progress report indicated that she had completed 8 out of 10 sessions of physical therapy for her SI joint pain and dysfunction. She continued to have lumbar pain reaching grade 7 out of 10 at maximum. The patient reported that she did not have relief of her back pain. She was not able to tolerate prolonged standing or sitting. Rehabilitation potential was noted as good, and 18 additional visits were recommended. The 10/6/17 spine surgeon report cited a chief complaint of right sided low back pain. Conservative treatment had included multiple anti-inflammatory agents, Neurontin, cyclobenzaprine, two right SI joint injections, and physical therapy. The first right SI joint injection lasted about four months and decreased her pain from grade 9 out of 10 to grade 2 out of 10. A second right SI joint injection did not provide benefit. She had right sided low back pain that occasionally radiated to the right buttocks but she did not have pain down either leg. Aggravating factors included prolonged standing and any repetitive motion of the lumbar spine. Lumbosacral examination documented tenderness over the right SI joint, left pelvic upslip, positive right Fortins testing, and positive right thigh thrust, FABERs, and compression testing. Lower extremity neurologic examination was within normal limits. Her gait was noted as normal and she was able to stand without difficulty. Lumbar spine MRI was reviewed and documented disc degeneration at L5/S1 with a small central disc protrusion abutting but not displacing the S1 nerve roots. The diagnosis was documented as right sacroiliac dysfunction. She had completed maximum conservative treatment for the right SI joint dysfunction and effectiveness of the right SI joint injection. She was assessed as an excellent candidate for right SI joint fusion. The patient has requested authorization and coverage for SI joint fusion. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of this patient. The guidelines for the requested procedure include the North American Spine Society (NASS), International Society for the Advancement of Spine Surgery (ISASS), and the National Institute for Health and Care Excellence (NICE). Nationally recognized evidence based medical guidelines support SI joint fusion (either open or percutaneous) on a case by case basis as a last line of therapy for the following conditions, with on-going symptoms, corroborating physical exam findings and imaging, and after failure of non-operative treatment: SI joint infection, tumor, disabling pain due to sacroiliitis due to spondyloarthropathy, sacroiliac pain due to severe traumatic injury, and in conjunction with multisegmental spinal constructs (i.e., scoliosis or kyphosis surgery). Suggested physical examination indicators of pain related to SI joint pathology include documentation of at least three positive examination findings to suggest the diagnosis. The five tests most recommended include the pelvic distraction test, pelvic compression test, thigh thrust test, FABER (Patricks test) and Gaenslens test. Polly and colleagues concluded in their Level 1 study that minimally invasive SIJ fusion using triangular titanium implants was more effective than nonsurgical management at one year in relieving pain, improving function, and improving quality of life in patients with SIJ dysfunction caused by degenerative sacroiliitis or SI joint disruptions. Pain, disability, and quality of life also improved after crossover from nonsurgical to surgical treatment. The ISASS policy statement for minimally invasive SI joint fusion also provide specific indications for surgery. In this patients case, the clinical examination findings have documented right SI joint tenderness with three positive sacroiliac provocative tests. There is no evidence of right SI joint degeneration. SI joint injections have been documented with 100% relief during the anesthetic phase. Current evidence based medical guideline and peer reviewed surgical indications for SI joint fusion have been met based on the history of this patients injury. This patient presented with persistent and progressively worsening right SI joint pain since 2013. Moreover, there is evidence of trial and failure of long term conservative treatment modalities including medications, activity modification, therapeutic right SI joint injections, and focused physical therapy. Accordingly, the SI joint fusion is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.