Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

The patient is a 45-year-old female who has a history of chronic low back and hip/buttock/tailbone pain, radiating into the leg above the knee with numbness and tingling. The pain developed gradually in November 2013 without trauma. She is status post L3-4 posterior spinal fusion and decompression (PSFD) and transforaminal lumbar interbody fusion (TLIF) on 7/17/15 and right sacroiliac joint fusion on 2/17/17. She underwent a left sacroiliac joint corticosteroid injection on 5/01/17. Radiological examination and arthrography of the left sacroiliac joint documented that there were no hypertrophic changes or other structural abnormalities. On 6/01/17, the records noted that the patient had good relief for one month after the left sacroiliac joint injection. She underwent an L3-L5 PSFD/TLIF on 11/11/17. She had undergone a similar procedure on the right with excellent results. In a letter dated 5/29/18, the patient reported that her left sacroiliac joint deterioration/dysfunction was causing severe pain, weakness and instability of her left leg. She had tried injections, medications, ice/heat, braces, supports and therapy. She had no relief with these treatments. In a letter dated 7/30/18, the patient indicated that she had exhausted all conservative/non-operative treatment for greater than six months for sacroiliac joint degeneration and dysfunction, including rest, medications, physical therapy, home exercise, braces and supports, trigger point injections, and sacroiliac joint injections. She reported that the left sacroiliac joint injections on 4/04/16 and 5/01/17 provided 75% short term improvement. X-rays/magnetic resonance imaging (MRI) of the left hip area showed no evidence of intra-articular hip joint pathology. Per the patient, she had several positive left sacroiliac joint provocative testing procedures documented in her medical records. The patient has requested coverage for left sacroiliac joint fusion. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of this patient.  This patient presents with complaints of constant left hip/groin and buttock area pain radiating down the leg. She reports associated swelling, weakness, and left leg instability. Functional limitations are noted in activities of daily living. The records indicate that she has undergone sacroiliac joint injections with temporary relief of greater than 75%. She has reportedly failed available conservative treatment options, including activity modification, medication, bracing, physical therapy, home exercise, trigger point injections, and sacroiliac joint injections. There is clinical examination evidence of four positive sacroiliac joint provocative tests. Current evidence-based medical guidelines and peer-reviewed surgical indications for sacroiliac joint fusion have been met. Therefore, the requested left sacroiliac joint fusion is likely to be more beneficial than other treatment options. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.