Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that low back pain (LBP) is highly prevalent in the Medicare population with reports of 50 to 
84% of adults experiencing back pain at some point and is the highest cause of disability globally. 
Approximately 15% to 30% of patients with persistent mechanical LBP below L5 have pain arising from their 
sacroiliac joints (SIJ). SIJ dysfunction is common after spinal fusion; and reported in up to 40% in some 
studies. The SIJ is a complex structure; it is a diarthrodial joint with matching articulate surfaces between the 
sacrum and ilium separated by synovial fluid and surrounded by a fibrous capsule. It is only a true synovial 
joint in the anterior portion, due to discontinuity of the posterior capsule. It serves as the biomechanical 
mediator between the spine and the pelvis. The joint is responsible for flexion and extension of the sacrum with 
counterrotation of the ileum and there is only a small amount of movement. The complexity of the joint is in 
the small degree of movement of the joint and the functional supporting structures of the joint (mainly the 
muscles, fascia and ligamentous connections). 
 
The SIJ goes through many changes throughout life. In early childhood, the surfaces of the joint are smooth 
and allow gliding motions in many directions. After puberty, the surface of the ilium becomes rougher and 
coated with fibrous plaques that will restrict motion significantly. These age-related changes will increase in 
the third and fourth decade and by the sixth decade, motion may become noticeably restricted. By the eighth 
decade, plaque will form, and erosions will be present. The SIJ has variable joint capacity as the SIJ 
degenerates with age and has varied from 0.5-2.5 ml. 
 
In addition to conservative and surgical modalities, interventional procedures are used for treatment of SIJ pain. 
This includes SIJIs and radiofrequency ablation (RFA) of the SIJ. Injections typically are intra-articular and 
contain anesthetic and corticosteroids. Ablation relies on RF-generated thermal energy to ablate the sensory 
nerve fibers of the SIJ, thereby interrupting nociceptive signals. 
 
The treatment of individuals with spinal disorders, including pain, can be complex, and it is recommended that 
all individuals being considered for interventional spinal procedures undergo a thorough evaluation and be 
treated following development of a comprehensive care plan. 
 
 A. SIJIs will be considered medically reasonable and necessary when all the following requirements are met: 
 
Moderate to severe LBP primarily experienced over the anatomical location of the SIJs between the upper level 
of the iliac crests and the gluteal fold, AND 
LBP duration of at least 3 months, AND 
LBP below L5 without radiculopathy, AND 
Clinical findings and/or imaging studies do not suggest any other diagnosed or obvious cause of the 
lumbosacral pain (such as central spinal stenosis with neurogenic claudication/myelopathy, foraminal stenosis 
or disc herniation with concordant radicular pain/radiculopathy, infection, tumor, fracture, pseudoarthrosis, or 
pain related to spinal instrumentation), AND 
At least 3 positive findings with provocative maneuvers: FABER, Gaenslen, Thigh Thrust or Posterior Shear, 
SI Compression, SI Distraction and Yeoman Tests, AND 
LBP persists despite a minimum of 4 weeks of conservative therapies. 
 
SIJ Denervation (also called Radiofrequency Ablation or RFA) is not considered reasonable and necessary. 
 
You can find these rules in the Local Coverage Determination (LCD) Sacroiliac Joint Injections and 
Procedures L39402. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.