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 joint fusion. In peer-reviewed medical literature, researchers provided evidence that minimally invasive SI joint fusion using triangular porous coated implants placed across the SI joint improved pain, disability and quality of life at 24 months in patients with SI joint dysfunction due to degenerative sacroiliitis and SI joint disruption, and was associated with a decrease in opioid usage for SI joint or low back pain. The International Society for Advancement of Spine Surgery  policy statement for minimally invasive SI joint fusion provide specific indications for surgery including 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 chronic low back pain radiating down both legs to the heels. Functional limitations are noted in activities of daily living, ambulatory ability, and work ability. She is reportedly using a cane for ambulation. Records document two positive SI joint provocative tests on clinical examination. The provider reports the patient underwent SI joint injection with temporary relief, but there was no documentation to support a 75% decrease in pain. She has been diagnosed with sacroiliitis and lumbago with sciatica. However, there is no imaging study presented to evidence SI joint spondyloarthropathy, degenerative sacroiliitis, or SI joint disruption. There is imaging evidence of L4-5 disc pathology and mild to moderate lateral recess stenosis and L5-S1 mild facet arthropathy. Current medical literature supports minimally invasive SI joint fusion for patients with SI joint dysfunction due to degenerative sacroiliitis or SI joint disruption. Overall, current evidence based medical guidelines state that SI joint fusion is not supported as treatment for patients with mechanical low back pain, non-specific low back pain, and SI joint disruption in the absence of major pelvic fracture, degenerative sacroiliitis, and SI joint osteoarthritis or SI joint mediated pain. In this case, there is a lack of evidence of a condition for which SI joint fusion is supported by current medical evidence. Additionally, there is concern for lumbar spine pain generation given the reported positive response to epidural injections. Therefore, the requested SI joint fusion is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that requested SI joint fusion is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested procedure is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.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.