Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Surgical Services (All). 
The insurer denied Radiofrequency ablation (RFA) as experimental/investigational. 
The denial was upheld.

This is a female patient diagnosed with sacroiliac joint dysfunction and adductor tendinitis. Records provided indicate the patient has a history of abdominal/pubic pain that worsened following childbirth. It is noted that the patient tried, and failed conservative management including physical therapy and medications and subsequently underwent multiple sacroiliac joint steroid injections that were noted to be beneficial providing significant pain relief, however, symptoms returned.

The progress note indicated the patient had complaints of back pain that does not radiate. The physical examination showed no abnormal exam findings. The provider states that the patient cannot continue repeating sacroiliac joint steroid injections and it was recommended the patient undergo radiofrequency ablation of the sacroiliac joints as the only other alternative would be sacroiliac joint fusion.

The magnetic resonance imaging (MRI) scan of the pelvis revealed mild chronic tenoperiosteal avulsion the common adductor-rectus abdominis aponeurosis, left greater than right with osteophytes and capsular scarring around the pubic symphysis but no stress reaction. There was mild bilateral sacroiliac joint osteoarthritis without edema pattern or stress reaction at the sacroiliac (SI) joints.
At issue is whether the Radiofrequency ablation (RFA) is likely to be more beneficial than any standard treatment or treatments.

The health plan's determination regarding the proposed health service or treatment is upheld in whole.

No, the RFA is not likely to be more beneficial than any standard treatment or treatments for the insured's condition.
Per evidence based Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG) guidelines, Sacroiliac Radiofrequency Neurotomy for Hip and Pelvis Conditions is "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 history of abdominal/pubic pain that worsened following childbirth. The MRI scan showed mild evidence of sacroiliac joint arthritis. It was noted that the patient tried, and failed conservative management including physical therapy and medications and subsequently underwent multiple sacroiliac joint steroid injections that were noted to be beneficial providing significant pain relief, however, symptoms returned. The provider recommended the patient undergo radiofrequency ablation stating that the only alternative would be a sacroiliac joint fusion. However, the requested treatment of RFA is experimental, investigational, and unproven. Studies do not establish this treatment as safe or effective and this procedure is not considered the standard of care.
The proposed health service or treatment Radiofrequency ablation (RFA) is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.