Appeal type: Medical Necessity
Decision: Overturned

Summary  
The patient is a 59-year-old female who presented to her provider 6/1/20. The records reported 
multiple diagnoses including degeneration of the lumbar and lumbosacral intervertebral discs, 
prolapsed lumbar intervertebral disc, low back pain, and sciatica. The patient has requested 
authorization and coverage for 27096  inject sacroiliac joint. The Health Insurer has denied this 
request and reported that the requested service is not medically necessary for the treatment of this 
patient. This denial is the subject of this appeal and determination. The physician reviewer found 
that the submitted documentation supports the medical necessity of the requested service. Evidence 
regarding the use of sacroiliac (SI) joint injections in the management of SI joint pain is limited. 
In a systematic evaluation of the therapeutic effectiveness of sacroiliac joint interventions, Hansen 
and colleagues concluded that the evidence is poor for the short-term and long-term relief from 
intraarticular steroid injections. In a review of the literature to establish an algorithm for the 
diagnosis and treatment of patients with SI joint pain, Falowski and colleagues report that 
conventional  non-surgical  therapies  such  as  medications,  physical  therapy,  radiofrequency 
denervation, and direct SI joint injections may have some limited durability in therapeutic benefit 
and have been relied on as frontline therapies, however, they have shown limited durability in 
therapeutic benefit. The authors further note that it is generally accepted to start with conservative 
measures such as nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, and physical 
therapy, and that an SI joint injection, whether diagnostic or therapeutic, can also be considered as 
part of both the early diagnostic and treatment algorithm and may yield more clarity for patient 
identification for further treatment options if conservative measures fail. Regarding the diagnosis 
and interventional pain management options for SI joint pain, Chuang and colleagues report, 
Multiple options for interventional treatment of chronic SI pain are available. The different 
assessments and critical appraisal systems for clinical evidence provide a framework for the 
decision-making process. However, the authors further report that intra-articular steroid injection, 
peri-articular prolotherapy, pulsed radiofrequency, and conventional monopolar radiofrequency 
have limited or poor evidence supporting their effectiveness in treating SI pain and conclude with 
the following recommendations for management of patients with SI joint pain, Physical therapy 
and NSAIDs are the first-line choices. Intra-articular steroid injection, radiofrequency ablation, 
and prolotherapy can be considered as interventional pain management options for SI joint pain 
relief. Lastly, regarding the nonoperative treatment options for patients with SI joint pain, Prather 
and colleagues note, The accepted method of treatment of patients with SI joint pain includes a 
trial of multiple methods of treatment that should be guided by the patient's history and clinical 
symptom complex. Caution should be taken to not to continue to mobilize the joints of patients 
with increase joint mobility or connective tissue laxity. Procedures including injections and 
radiofrequency denervation of the SI joint can be useful tools to reduce pain when noninvasive 
treatments  are  unsuccessful.  In  this  case,  the  records  document  degenerative  lumbar  and 
lumbosacral intervertebral discs, prolapsed lumbar intervertebral disc, low back pain, and sciatica. 
In this clinical setting, current medical literature suggests that while SI joint injections have poor 
evidence  of  efficacy,  they  may  be  useful  when  multiple  methods  of  treatment  including 
conventional non-surgical therapies such as oral analgesic use, physical therapy, NSAIDs, and 
muscle relaxants are unsuccessful. In this case, the records note that the patient has tried physical 
therapy, a sacroiliac joint injection, and medication management with NSAIDs such as ibuprofen, 
muscle relaxants such as tizanidine, and oral analgesics such as Percocet. In this clinical setting, 
given that the records demonstrate a benefit from past injections along with a lack of efficacy of 
several other conservative measures including physical therapy and medications, the requested  service is medically indicated. Therefore, 27096  inject sacroiliac joint is medically necessary for 
the treatment of this patient.