Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ankylosing spondylitis
Treatment: Pain Injection (27096 x2) (Bilateral Sacroiliac Joint Injections)
The insurer denied: Pain Injection (27096 x2) (Bilateral Sacroiliac 
Joint Injections)
The denial is upheld

The patient is a n adult male. The patient is diagnosed with ankylosing spondylitis. The provider confirms that they have no additional information to submit. MRI (magnetic resonance imaging) of the sacroiliac joints revealed mild arthrosis of the sacroiliac joints. Procedure report shows the patient underwent bilateral SI (sacroiliac) joint injections. There is a progress note from last year noting that the patient had 50% (percent) relief with SI (sacroiliac) joint injections previously completed. MRI (magnetic resonance imaging) of the sacroiliac joints revealed mild sacroiliac joint arthrosis with marrow edema, posteriorly on the left. This is better visualized than on the prior study. MRI (magnetic resonance imaging) of lumbar spine dated 3 months ago revealed straightening of the normal lumbar lordosis. Mild diffuse disc bulge at L4 - L5 (lumbar four to lumbar five) without significant spinal stenosis was noted. The patient noted that a rheumatologist diagnosed him with ankylosing, spondylitis. The patient tried Humera, which did not help any, and they recommended pain management. The patient saw another provider, who did bilateral SI (sacroiliac) joint injections approximately three months prior with temporary relief and recommended a second injection. Conservative treatment has included heat, and physical therapy made the pain worse. The patient has tried diclofenac and Voltaren gel. The pain is located in the low back and described as dull and aching. Physical examination revealed lumbar paraspinal spasm and tenderness as well as SI (sacroiliac) joint tenderness. The patient's motor strength was 5/5. The patient had positive Kemp maneuver with facet loading. His sensation was intact.
There is an addendum on this report noting that the patient had positive SI (sacroiliac) compression, positive FABER (Flexion, Abduction and External Rotation) and positive Patrick's test on physical examination, though it is unclear why this was not documented on the original examination.
There is a second addendum on this same report noting that the patient had bilateral sacroiliac joint injections last year with sustained relief of 85% lasting for greater than three months and the pain has now returned. It should be noted that the "85" was handwritten over top of a number that was originally there in the typed report.

The requested bilateral sacroiliac joint injections are not medically necessary.

Records provided indicate the patient has a history of low back pain, and although the most recent lumbar MRI (magnetic resonance imaging) does not show any findings related to the SI (sacroiliac) joints, there were two prior MRI (magnetic resonance imaging) reports of the sacroiliac joints showing mild sacroiliac joint arthrosis. However, the patient previously underwent bilateral SI (sacroiliac) joint injections and the follow-up note states that the patient had only 50% pain relief. Although there is an addendum on the progress note noting that the patient had 80% relief, this is handwritten over top of whatever number was previously there. It should also be noted that in the actual progress note provided, physical exam did not show a positive response release to three SI (sacroiliac) joint pain provocative tests. There was a subsequent addendum on the report stating that the patient had positive SI (sacroiliac) compression, positive FABER (Flexion, Abduction and External Rotation) and positive Patrick's test on physical examination. However, this was noted after the fact and was not actually noted on the physical examination, which only showed positive Kemp's test with facet loading along with lumbar paraspinal spasm and tenderness. Given the above, the injections are not medically necessary.