Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Low Back Pain; Sacroilitis

Treatment: Sacroiliac (SI) joint injection

The insurer denied coverage for sacroiliac (SI) joint injection.

The denial is overturned.

This female patient with a past history of back injury from a fall down a flight of stairs. Per documentation, the patient was noted to have primary diagnosis of sacroilitis. At the time of the injury, the patient underwent spinal injections at that time which she reported gave her pain relief for 25 years. The current pain episode started 6 years prior without any antecedent trauma or accident with pain radiating down to her right leg and toes and with tingling numbness, electric shock-like sensation in her leg which occasionally happened in the left leg as well. The patient's chronic back pain was noted as starting more than 1 year prior and was constant and described as aching and radiating to the right foot, right thigh and right knee with pain severity of 10/10 that was associated with numbness and paresthesia. The patient's physical exam noted reduced range of motion of the lumbar spine in flexion and extension. Also noted was tenderness to palpation of lumbar spine at the midline in mid-to-lower lumbar spine, and paravertebral tenderness and sacroiliac (SI) joint tenderness (right-side worse than the left-side). These clinical findings were consistent with this patient's symptomology. The patient was currently being treated with cyclobenzaprine. The patient's magnetic resonance imaging (MRI) report indicated impression of mild degenerative changes with no significant central or foraminal encroachment and no disc protrusions. A progress note showed that the patient's pain was unchanged and rated 8/10, in severity. The treatment plan included continuation of meloxicam; injection therapy was discussed with the patient as solution to her pain. The patient had a trialed physical therapy. A telephone visit noted that the patient's pain was unchanged with treatment with Meloxicam and Flexeril, which was given by her primary care doctor. The patient's provocative testing including sacral thrust test, Fortin finger test sign and Patrick sign were all tested positive. The physician has recommended sacroiliac (SI) joint injection.

As per Rashbaum, et al. (2016), "Clinically, the [sacroiliac joint (SIJ)] can be challenging to evaluate; however, assessing pain location, patient posture/movement, and provocative manual testing are useful in making the presumptive diagnosis of SIJ disruption. The most definitive evaluation is image-guided injection of anesthetic solutions into the joint which is diagnostic if there is at least 75% symptom relief acutely." Similarly, Schmidt et al (2018) states that "Sacroiliac joint (SIJ)-based pain can be difficult to diagnose definitively through physical examination and conventional radiography. A fluoroscopically guided injection into the SIJ can be both diagnostic and therapeutic... Surgical treatment is indicated for patients with a positive response to an SI injection with >75% relief, failure of nonsurgical treatment, and continued or recurrent SIJ pain."

The diagnostic imaging test of choice for sacroiliac (SI) joint is a computed tomography (CT) scan, not a magnetic resonance imaging (MRI). While the patient does have facet arthropathy at multiple levels, the physical exam signs of Sacral Thrust test, Patrick's sign and Fortin Finger test sign do support the SI joint as a pain generator. Based on the review of the medical literature, it would be medically necessary to confirm this patient's SI joint dysfunction by performing a diagnostic injection. Thus, sacroiliac (SI) joint injection is considered medically necessary for this patient.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient. 

The carrier's denial of coverage for sacroiliac (SI) joint injection should be overturned. The medical necessity is substantiated.