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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sacroiliac (SI) joint fusion surgery. In the peer-reviewed medical literature, researchers performed a Level 1 study on patients with SI joint dysfunction. The authors concluded that 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. Applying the International Society for Advancement of Spine Surgery (ISASS) criteria, this patient meets the requirements for minimally invasive SI joint fusion. The ISASS criteria include: significant SI joint pain or significant limitations in activities of daily living because of SI joint pain; 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 including medications, rest, physical therapy, and SI joint steroid injection or rhizotomy; and, additional or alternative diagnoses that could be responsible for the patients ongoing pain or disability have been considered, investigated and ruled-out. This patient presents with persistent severe right-sided SI joint pain that interferes with her ability to perform activities of daily living. Clinical examination findings have documented SI joint tenderness with three positive SI provocative tests consistent with imaging evidence of mild anterior degenerative spurring of the right upper SI joint consistent with degenerative SI joint disease. Further, the records include evidence of at least six months of conservative treatment with medications, SI joint injections, home exercise program, and physical therapy without sustained improvement. Further, she reported 100% symptom relief in the immediate post-injection period following the right SI joint injection. Lumbar pathology has been considered, investigated and ruled-out as the primary pain generator. Thus, the current evidence-based medical guideline and peer-reviewed surgical indications for SI joint fusion have been met. Therefore, the requested SI joint fusion surgery is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. One reviewer found that Final Result: Two of the three 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:  One reviewer is board certified in orthopedic surgery and is actively practicing. One Reviewer is board certified in orthopedic surgery and is actively practicing.  One Reviewer is board certified in orthopedic surgery and is actively practicing.  All three 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.