Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sacroiliac Joint Pain. 
Treatment: Surgical fusion of left sacroiliac joint (surgery to the lower buttock/hip joint) Code 27279 

The insurer denied coverage for surgical fusion of left sacroiliac joint (surgery to the lower buttock/hip joint) Code 27279. 

The denial is overturned. 
 
This case involves an adult patient diagnosed with sacroiliac joint pain who underwent left sacroiliac joint fusion.  The patient received a notice of adverse determination regarding the sacroiliac joint fusion with claims that the patient was not a candidate for the procedure with reports that there was no documented pain radiating into the patient's legs, lateral thighs, or into the knees.  There was no documentation indicating the patient has joint pain that interferes with activities of daily living and no documentation of reduction in pain by 75% or greater for expected duration of the effect of the local anesthetic agent used during 2 separate contrast-enhanced fluoroscopically or computed tomography (CT) guided intra-articular sacroiliac joint blocks.  There were also no records documenting a minimum of 6 months conservative care with nonsurgical treatment of physician supervised/prescribed active physical therapy or consecutive 6 months of conservative, nonsurgical treatment of chiropractic care.  Lastly, there was recent magnetic resonance imaging (MRI) showing concomitant neural compression or other degenerative condition. 

The records provided for the review included physical therapy notes dating back a few years, and injection note and diagnostic imaging.  Prior relevant treatment included non-steroidal anti-inflammatory drugs (NSAIDs) along with the sacroiliac (SI) joint injection.  The patient reported 2 weeks pain relief following the SI injection before her pain gradually returned.  When the patient was seen the report noted positive Fortin finger test, positive Faber test for lateral hip/lower back pain, positive Gaenslen's test, positive thigh thrust, positive compression and distraction testing on the left.  There was tenderness to palpation at the left SI joint with reduced range of motion and positive paraspinal spasms. 

Current literature has stated that for patients with chronic sacroiliac joint pain due to joint degeneration or disruption, minimally invasive sacroiliac joint arthrodesis with triangular titanium implants has been found to be safe and more effective throughout 2 years and improving pain, disability, and quality of life compared with conservative management.  Literature states that while the majority of patients can achieve adequate pain relief with conservative techniques, for recalcitrant cases, minimally invasive transected like fusion surgery is an option.  

Based upon the provided documentation, the patient was a suitable candidate for the surgery completed. She had confirmed evidence of sacroiliitis, failed conservative management, and had a positive response to sacroiliac joint injections.  As such, the request for surgical fusion of the left sacroiliac joint with CPT code 27279 was medically necessary. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for surgical fusion of left sacroiliac joint (surgery to the lower buttock/hip joint) Code 27279 is substantiated.