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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sacroiliac (SI) joint fusion surgery (CPT code 27279 LT). SI fusion maybe recommended on a case-by-case basis as a last line of therapy as treatment for SI joint infection, tumor involving the sacrum, disabling pain due to sacroiliitis/spondyloarthropathy, or SI pain due to severe traumatic injury. SI fusion is not recommended for mechanical low back pain, non-specific low back pain, SI joint disruption, degenerative sacroiliitis, SI joint osteoarthritis, or SI joint-mediated pain. The authors indicated that surgery can be beneficial for fracture or dislocation, but the application to degenerative disease was less clear. The North American Spine Society (NASS) supports SI fusion under limited conditions, if stringent diagnostic criteria have been met. NASS uses diagnostic intra-articular injections with local anesthetic with at least 75% pain relief as a criterion to diagnose pain related to the SI joint, and they recommend a confirmatory injection. NASS also recommends diagnostic imaging to rule out destructive lesions or inflammatory arthropathy of the SI joint, hip pathology, and/or neural compression or other degenerative condition of the lumbar spine that could cause low back or buttock pain. The guidelines also recommend imaging to rule out injury and degeneration, followed by a trial of at least one successful therapeutic intra-articular injection. Researchers performed a systematic review evaluating the clinical efficacy of SI joint fusion. The authors found that surgical intervention appeared beneficial in a subset of patients, but due to difficulty in making an accurate diagnosis and evidence for the efficacy of the actual procedure itself, other causes of pain and alternative treatment should be considered prior to performing the procedure. In this case, the patient has chronic low back and bilateral SI pain. Physical examination findings localize some of her symptoms to the SI joints. However, the patient has concurrent lumbar pathology and she reportedly experienced relief from a lumbar epidural steroid injection, which does not support the SI as the patients main pain generator. In addition, the submitted records do not include imaging or laboratory findings demonstrating the presence of SI joint infection, tumor or sacroiliitis, due to spondyloarthropathy or post-traumatic arthritis, which are accepted conditions for performing SI fusion. All told, the requested SI joint fusion surgery (CPT code 27279 LT) is not likely to be more beneficial than any other available standard treatments for the patients medical condition.Findings:  Two of the three physician reviewers found the requested SI joint fusion surgery (CPT code 27279 LT) is not likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. 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.