Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low back pain. 
Treatment: outpatient services 27096 x 2 (pain injections). 
The insurer denied coverage for outpatient services 27096 x 2 (pain injections). 
The denial is upheld. 

According to the documentation provided, this is an adult with a 17 year history of low back pain, who has been diagnosed with sacroiliac joint (SIJ) dysfunction. SIJ injections have been recommended. The pain does not radiate. Pain is rated at 10/10. Pain is described as stabbing, aching. Her pain is exacerbated by bending, standing. Her pain is relieved with anti-inflammatory medications. She has had physical therapy, acupuncture, aqua therapy, epidural injections, and medial branch blocks without much pain relief. MRI reveals progression of lower lumbar facet arthrosis. Physical exam reveals positive facet loading maneuvers, tenderness, positive right and left Fortin Finger test, positive right and left Gaenslen's test. Patients who fail conservative treatment may require periarticular or intra-articular corticosteroid for pain relief. 

According to Centers for Medicare and Medicaid (CMS) guidelines (Sacroiliac Joint Injections and Procedures - DL39402. https://www.cms.gov/medicare-coverage database/view/lcd.aspx?lcdId=39401&ver=12) Sacroiliac joint injections (SIJI) will be considered medically reasonable and necessary when all the following requirements are met: 1) Moderate to severe low 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 (lumbar) 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:  Flexion Abduction and External Rotation (FABER), Gaenslen, Thigh Thrust or Posterior Shear, SI (sacroiliac) Compression, SI Distraction and Yeoman Tests,3,4 AND 6) LBP persists despite a minimum of 4 weeks of conservative therapies. 

The patient does not meet all of the CMS or Centene criteria for SIJI to be considered medically reasonable and necessary. There is physical exam evidence (positive facet loading maneuvers) and MRI evidence (progression of lower lumbar facet arthrosis) of facet joint mediated pain. CMS and Centene guidelines state that for SIJI to be considered medically reasonable and necessary the clinical findings and/or imaging studies should not suggest any other possible cause of lumbosacral pain such as facet joint arthrosis. In addition, CMS and Centene guidelines require at least 3 positive findings with provocative SIJ maneuvers. While the patient does have tenderness and positive bilateral Gaenslen's tests, there is no mention in the medical record of a third positive provocative SIJ maneuver. Fortin Finger test is not considered a provocative maneuver, it is simply a patient pain localization test. Up to Date also notes the uncertain effectiveness of SI joint injection. 

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 outpatient services 27096 x 2 is not substantiated.