Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Surgical Services (All). 
The insurer denied Radiofrequency ablation (RFA) as experimental/investigational. 
The denial was upheld.

This is a female patient diagnosed with sacroiliac joint dysfunction and adductor tendinitis.
The patient was seen for a follow-up visit with chief complaint of low back pain gradually returning since the last injection described as aching and sometimes sharp. She has been using ibuprofen 2-3 times per day. The pain does not radiate down the legs. She has no numbness or tingling in the legs. It was noted that the patient was status post bilateral sacroiliac joint injections and had significant improvement on follow-up visit. She was recommended to continue her home exercise program. Her pain returned and repeated bilateral sacroiliac joint injections with steroids with the patient reporting 75% improvement. The injections were again performed with reports of near-complete pain relief after the injection. Her physical examination was unremarkable. It was felt the patient's pain was consistent with sacroiliac joint pain and recommended the patient undergo sacroiliac joint radiofrequency ablation.
A magnetic resonance imaging (MRI) scan of the pelvis revealed mild chronic tenoperiosteal avulsion, the common adductor-rectus abdominis aponeurosis, left greater than right with osteophytes and capsular scarring around the pubic symphysis but no stress reaction. There was mild bilateral sacroiliac joint osteoarthritis without edema pattern or stress reaction at the sacroiliac (SI) joints.
At issue is whether the treatment of Radiofrequency ablation (RFA) is likely to be more beneficial than any standard treatment.

The health plan's determination regarding the proposed health treatment is upheld in whole.

The proposed health service or treatment Radiofrequency ablation (RFA) is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
According to Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG), Sacroiliac Radiofrequency Neurotomy for Hip and Pelvis Conditions is not recommended due to the lack of evidence supporting use of this technique. The current treatment remains investigational. More research is needed to refine the technique of SI joint denervation, better assess long-term outcomes, and to determine what combination of variables can be used to improve candidate screening. There is also no consensus as to what is the most appropriate diagnostic test to use pre-procedure. Explanations for why approximately half of selected patients (using varying techniques for diagnosis and treatment) do not respond include a lack of information about accurate innervation and the possibility that the patient's pain may be secondary to anterior, and therefore untargeted, areas.
The patient is noted to have chronic low back pain that the provider feels is related to the sacroiliac joints. There was noted to be mild bilateral sacroiliac joint osteoarthritis without edema pattern or stress reaction at the SI joints on MRI. However, the requested procedure remains investigational as there is no high-quality evidence found in the peer-reviewed medical literature supporting this procedure to be effective and no evidence to suggest that this treatment would be more beneficial.
Therefore, the proposed health service or treatment Radiofrequency ablation (RFA) is not likely to be more beneficial than any standard treatment or treatments.