Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral sacroiliac (SI) joint fusion surgery. Polly and colleagues concluded that minimally invasive SI joint 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 SI joint dysfunction caused by degenerative sacroiliitis or SI joint disruptions. The International Society for Advancement of Spine Surgery (ISASS) policy statement for minimally invasive SI joint fusion provide specific indications for surgery (Lorio and Rashbaum). Per the ISASS, criteria include significant SI joint pain or significant limitations in activities of daily living because of SI joint pain confirmed by at least three positive SI joint provocative tests, confirmation of the SI joint as a pain generator with at least 75% decrease in pain following fluoroscopically guided diagnostic intra-articular SI joint block in the immediate post-injection period, failure to respond to at least six months of non-surgical treatment, and alternative diagnoses that could be responsible for the patients ongoing pain or disability have been ruled-out. This patient presents with a history of bilateral SI joint pain. She has a history of trauma in 1989 and is status post L5-S1 anterior lumbar interbody fusion more than 20 years ago. She is reporting grade 3-10/10 debilitating bilateral SI joint pain. Functional limitations are noted in walking, standing, and sitting. Clinical examination findings have documented bilateral SI joint pain to palpation and five positive provocative SI joint tests. She has failed long-term comprehensive conservative treatment, including activity modification, medications, and physical therapy. She has undergone bilateral sacroiliac joint injections with 100% short-term relief of symptoms. CT scan of the lumbar spine documented a solid fusion and no significant pathology consistent with pain generation. CT scan of the pelvis showed bilateral SI joint vacuum phenomenon and sclerosis with subluxation of her coccyx anteriorly. Current evidence-based medical literature criteria have been met to support bilateral SI joint fusion in this patients clinical setting. For these reasons, the requested bilateral SI joint fusion surgery is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested bilateral SI joint fusion surgery is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.