Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested sacroiliac joint fusion for treatment of the enrollees sacroiliac (SI) joint pain.  Findings: Two physician reviewers found that evidence based medical guidelines support SI joint fusion (either open or percutaneous) on an individual basis as a last line of therapy for ongoing symptoms, corroborating physical exam findings and imaging, and after failure of non-operative treatment for SI joint infection, tumor, disabling pain due to sacroiliitis due to spondyloarthropathy, SI pain due to severe traumatic injury, and in conjunction with multisegmental spinal constructs. Suggested physical exam indicators of pain related to SI joint pathology include documentation of at least three positive exam findings to suggest the diagnosis. The five tests most recommended include the pelvic distraction test, pelvic compression test, thigh thrust test, FABER (Patricks test) and Gaenslens test. Polly and colleagues concluded in their study that minimally invasive SI joint fusion using triangular titanium implants was more effective than nonsurgical management at one year in relieving pain, improving function, and improving quality of life in patients with SI joint dysfunction caused by degenerative sacroiliitis or SI joint disruptions. Pain, disability, and quality of life also improved after crossover from nonsurgical to surgical treatment. The International Society for Advancement of Spine Surgery (ISASS) policy statement for minimally invasive SI joint fusion provide specific indications for surgery. Criteria include: significant SI joint pain or significant limitations in activities of daily living because of SI joint pain; SI joint pain confirmed by at least three positive SI joint provocative tests; confirmation of the SI joint as a pain generator with at least 75% decrease in pain following fluoroscopically guided diagnostic intra-articular SI joint block in the immediate post-injection period; failure to respond to at least six months of non-surgical treatment including medications, rest, physical therapy, and SI joint steroid injection or rhizotomy; and additional or alternative diagnoses that could be responsible for the patients ongoing pain or disability have been clearly considered, investigated and ruled-out. This patient presents with chronic left-sided SI joint pain. There is imaging evidence of small anterior bridging osteophytes at the SI joints. Detailed evidence of a recent, reasonable and/or comprehensive non-operative treatment protocol trial and failure has been submitted. However, there are no positive physical exam findings to support the diagnosis of SI joint dysfunction. There is no evidence of SI joint tenderness or positive SI joint provocative testing consistent with evidence based medical guidelines. A positive diagnostic SI joint injection was documented with 60% pain relief which did not meet the ISASS criteria for proceeding with fusion. For these reasons, the requested SI joint fusion is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the requested service is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three physician reviewers are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.