Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain.
Treatment: Sacroiliac joint radiofrequency ablation (SIJ RFA).
The insurer denied: sacroiliac joint radiofrequency ablation (SIJ RFA).
The denial is: Upheld.

This is a female patient diagnosed with pain in the tailbone. A request for sacroiliac (SI) joint radiofrequency ablation was denied.
The patient was seen for follow-up visit regarding chronic low back pain radiating down the bilateral legs. Pain is rated at 10/10 and reported as worsening. Current pain medications include tizanidine, meloxicam, gabapentin, and Tylenol. The patient is not currently in physical therapy or doing a home exercise program. The patient complains of numbness and tingling in the bilateral upper legs as well as weakness in the bilateral legs. Symptoms are a bit worse than when she was last seen with ongoing pain in the lumbosacral and posterior pelvic region with occasional numbness and tingling into the legs but most symptoms at the posterior SI joint region.

Physical examination revealed minimal tenderness at the lumbar paraspinals, pain and stiffness with walking and also with flexion and extension of the lumbar spine. Tenderness to palpation at the posterior sacroiliac joint complex and posterior superior iliac spine (PSIS) region bilaterally. 5/5 strength in the lower extremities. The provider states that the patient has disc degeneration greatest at lumbar (L)5-sacral (S)1 as well as mixed Modic 1-2 changes at the end plates between L3-L4, L4-L5, and L5-S1 associated with small end plate defects. She previously had close to 100% reduction in pain after bilateral SI joint injections and up to 100% reduction in pain after bilateral sacral lateral branch blocks, but radiofrequency ablation was denied and is pending appeal. It was noted they will initiate Cymbalta; she is a candidate for spinal cord stimulator trial, and they will await results of the appeal for radiofrequency ablation of the SI joints. The subject under review is the medical necessity for surgery, sacroiliac joint radiofrequency ablation (SIJ RFA).

The health plan's determination is upheld.

The requested surgery to decrease pain in tailbone (SIJ RFA) is not medically necessary for this patient. Per Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG), "Not recommended due to the lack of evidence supporting use of this technique. 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."
Records provided indicate the patient has chronic back pain that radiates into the lower extremities with numbness and tingling and weakness. The provider notes the patient has magnetic resonance imaging (MRI) findings of disc degeneration greatest at L5-S1 as well as mixed Modic 1-2 changes at the end plates between L3-L4, L4-L5 and L5-S1 associated with small end plate defects. These findings do not suggest the SI joints as the primary pain generator. This procedure is not supported by evidence-based guidelines or peer-reviewed literature as there is a lack of evidence regarding long-term outcomes and additional studies are needed. Radiofrequency ablation of the SI joints is not considered the standard of care and it is not medically necessary.