Original Effective Date: 7/5/07 Guidance Number: MCG-033 Revision Date(s): 12/3/09, 8/23/12, 12/11/13, 6/12/14

Transcription

1 Subject: Sacriliac Injectins and Radifrequency Ablatin fr Sacriliac Jint Pain Original Effective Date: 7/5/07 Guidance Number: MCG-033 Revisin Date(s): 12/3/09, 8/23/12, 12/11/13, 6/12/14 Medical Cverage Guidance Apprval Date: 6/25/14 DISCLAIMER This Medical Guidance is intended t facilitate the Utilizatin Management prcess. It expresses Mlina s determinatin as t whether certain services r supplies are medically necessary, experimental, investigatinal, r csmetic fr purpses f determining apprpriateness f payment. The cnclusin that a particular service r supply is medically necessary des nt cnstitute a representatin r warranty that this service r supply is cvered (i.e., will be paid fr by Mlina) fr a particular member. The member s benefit plan determines cverage. Each benefit plan defines which services are cvered, which are excluded, and which are subject t dllar caps r ther limits. Members and their prviders will need t cnsult the member s benefit plan t determine if there are any exclusin(s) r ther benefit limitatins applicable t this service r supply. If there is a discrepancy between this plicy and a member s plan f benefits, the benefits plan will gvern. In additin, cverage may be mandated by applicable legal requirements f a State, the Federal gvernment r CMS fr Medicare and Medicaid members. CMS s Cverage Database can be fund n the CMS website. The cverage directive(s) and criteria frm an existing Natinal Cverage Determinatin (NCD) r Lcal Cverage Determinatin (LCD) will supersede the cntents f this Mlina medical cverage guidance (MCG) dcument and prvide the directive fr all Medicare members. FDA INDICATIONS Sacriliac injectins (SIJ) and radifrequency ablatin (RFA) are a prcedure which is nt subject t regulatin by the FDA. There are numerus devices listed in the FDA 510(k) Premarket Ntificatin database that are cleared fr radifrequency ablatin (RFA) therapy. 39 CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS) The cverage directive(s) and criteria frm an existing Natinal Cverage Determinatin (NCD) r Lcal Cverage Determinatin (LCD) will supersede the cntents f this Mlina medical cverage guidance (MCG) dcument and prvide the directive fr all Medicare members. The directives frm this MCG dcument may be fllwed if there are n available NCD r LCD dcuments available and utlined belw. There is n Natinal Cverage Determinatin (NCD) that addresses sacriliac jint injectins r radifrequency ablatin. A lcal cverage determinatin is available fr sacriliac jint injectins and utlines that the injectins are cvered fr bth diagnstic and therapeutic interventins fr lw back pain. 24 The pain must have been present fr greater than 3 mnths. Maximum f tw therapeutic injectins are cvered, ne t tw weeks apart. Therapeutic injectins can be perfrmed t each regin nce every tw t three mnths if 50% r greater pain relief is achieved. A maximum f fur therapeutic injectins per regin per year are allwed. Patients wh have gained n symptm relief f functinal imprvement after tw injectins f the SI jint shuld nt prceed with additinal injectins because the likelihd f pain relief after tw failed attempts is lw. 37 Page 1 f 13

2 INITIAL COVERAGE CRITERIA 1. Radifrequency ablatin and pulsed radifrequency fr diagnsing r treating acute, subacute, r chrnic SI jint pain are cnsidered experimental, investigatinal, r unprven and may NOT be authrized due t insufficient evidence in the peer reviewed literature Sacriliac injectins (lcal anesthetics with r withut crticsterids) with flurscppy are cnsidered medically necessary fr chrnic severely debilitating lw back pain when all f the fllwing criteria are met: [ALL] Adults wh are age 18 years r lder A cmprehensive pain evaluatin and treatment plan has been perfrmed by a qualified practitiner with pain management expertise in cnjunctin with a cmprehensive treatment plan (e.g., medicatins, rehabilitatin and psychlgical evaluatin and interventin); 21,22 and Physical examinatin dcumentatin reveals all f the fllwing clinical characteristics f sacriliac jint disease: Smatic r nnradicular lw back pain and lwer extremity pain (greater than 6 n scale 0-10) belw the level f L5 vertebra fr minimally three mnths; 21,22 and Intermittent r cntinuus pain causing functinal disability; 21,22 and Failure t respnd t 3 t 6 mnths f cnservative treatment management (e.g., physical therapy mdalities with exercise, NSAIDS, etc) 21,22 Initiatin f Treatment and Injectin Frequency fllwing Criteria Apprval In the diagnstic phase: A ttal f tw injectins fr diagnsis may be given n less than ne week apart, preferably tw weeks apart. 21,22 If the patient des nt experience 80% symptm r pain relief (using visual analg scale r verbal descriptr scale) fr a minimum f 6 weeks fllwing the secnd injectin, n further 21,22 54 injectins shuld be given In the therapeutic phase all f the fllwing criteria must be met: the previus diagnstic r therapeutic injectin prvided pain relief f 80% dcumented thrugh an bjective assessment f pain using a standardized pain assessment tl (e.g., visual analg scale, verbal descriptr scale) fr minimally 6 weeks befre subsequent injectins within the 21,22 54 same regin are authrized Page 2 f 13

3 The frequency shuld be 2 mnths r lnger between each injectin in the same jint nt t exceed a ttal f 4 injectins in ne regin per year. The injectins shuld nly be repeated as 21,22 54 necessary if the medical necessity criteria abve are achieved. Injectins at different jints can be given 2 weeks apart but n sner than 1 week fllwing an 21,22 54 injectin in a different regin. A maximum f 4 injectins ttal per rlling calendar year may be given fr lcal anesthetic and 21,22 54 crticsterid injectins. A patient must be experiencing a return f pain r deteriratin in functin t receive a therapeutic injectin. Ntes: *A rlling calendar year is twelve mnths after the event, beginning and ending in the same mnth the initial event tk place; (e.g., first diagnstic injectin is given in December 2013, the rlling calendar year wuld end in December 2014) When sacriliac jint dysfunctin is present in cnjunctin with ther primary pain generatrs (such as lumbar radiculitis secndary t degenerative disc disease r lumbar facet arthrpathy secndary t lumbar facet arthritis, treatment shuld first address the nn-sacriliac jint pain generatrs, as SI jint dysfunctin may reslve nce these pain generatrs have been successfully treated. If there is residual sacriliac pain, it may be apprpriate t perfrm SI jint injectins t address the remaining pain. 24 nly ne type f a blck r injectin (e.g., sacriliac, epidural) shuld be perfrmed in a given sessin s that the effectiveness f its treatment can be assessed prir t attempting anther type f spinal blck r injectin. 24 CONTINUATION OF THERAPY The frequency and scpe f service is utlined under the cverage criteria sectin f this dcument. Sacriliac jint injectins shuld nly be perfrmed with anesthetics and/r crticsterids. Refer t the Cverage Criteria sectin fr the number f apprved treatments. COVERAGE EXCLUSIONS 1. Lateral Nerve blcks and Radifrequency ablatin and pulsed radifrequency fr diagnsing r treating acute, subacute, r chrnic SI jint pain prcedures are cnsidered experimental, investigatinal, r unprven and may NOT be authrized due t insufficient evidence in the peer reviewed literature Sacriliac injectins are excluded fr the fllwing: Members that d nt meet the utlined Cverage Criteria listed abve Use f agents ther than lcal anesthetic agents with r withut crticsterids Page 3 f 13

4 Requests fr sacriliac injectins exceeding the limits utlined abve Treatment f patients with acute lw back and acute pain syndrmes Cntraindicatins t receiving sacriliac jint injectins include, but are nt limited t, the fllwing: Allergy t the medicatin t be administered Anticagulatin therapy Bleeding disrder Lcalized infectin in the regin t be injected Systemic infectin Other cmrbidities that culd exacerbate the prcedure/sterid use (e.g., diabetes, cngestive heart failure, prly cntrlled hypertensin) Flurscpy use is cntraindicated fr members that are pregnant DESCRIPTION OF PROCEDURE/SERVICE/PHARMACEUTICAL Sacriliac Jint Injectins: Intraarticular sacriliac jint injectins are perfrmed fr bth diagnstic and therapeutic purpses. Diagnstic injectins are perfrmed t cnfirm the lcatin f pain riginating in the sacriliac jint regin. The prcedure is perfrmed mst cmmnly using flurscpy guidance fr accurate needle placement. The needle is placed in the sacriliac jint regin and cntrast media is injected fr arthrgram viewing t cnfirm crrect needle placement. An injectin f a small amunt f anesthetic is injected t determine the patient s pain relief respnse. If pain is reduced by 50% r remved, a therapeutic injectin f anesthetic with r withut crticsterid wuld be prvided t achieve lng term pain relief. 1 Radifrequency Ablatin: Radifrequency ablatin (RFA) fr sacriliac (SI) jint pain invlves the use f radifrequency (RF) current t generate heat and destry sensry nerves t the SI jint. The gal f this therapy is t interrupt transmissin f pain signals frm the SI jint nerves t the brain in patients with refractry SI jint pain. 39 Pulsed Radifrequency: Pulsed RFA (PRFA) has been intrduced as a nnablative alternative t RFA. PRFA delivers shrt bursts f radifrequency (RF) current, instead f the cntinuus flw f RF current prduced by cntinuus RF generatrs. This allws the tissue t cl between bursts, resulting in cnsiderably lwer maximum temperatures as cmpared with the cntinuus mde, and reduces the risk f neighbring tissue destructin. It des nt destry targeted nerves and surrunding tissue and therefre requires less precise electrdes placement. During PRFA, intermittent lw temperature electric currents f 2 Hz at temperatures nt exceeding 42 C are transmitted t the nerve. 39 Bth RFA and PFRA are perfrmed in the utpatient setting. SIJ pain SIJ pain is mst cmmnly attributed t traumatic injury resulting frm direct impact n the buttcks, trauma invlving the lateral aspect f the pelvic ring, trsin frce frm lifting, pulling and twisting, and sudden gait Page 4 f 13

5 pattern changes frm miscalculated stepping resulting in height variatin changes. 2,5 Pes planus (fallen arches) can als develp int sacriliac pain. Pregnant wmen have a higher incidence f develping SI jint dysfunctin as prgesterne prductin may sften supprting ligaments causing hypermbility. GENERAL INFORMATION Summary f Medical Evidence Radifrequency Ablatin 12 studies that fcused n radifrequency ablatin (RFA) fr the treatment f sacriliac (SI) jint pain have been identified. Five studies each assessed cnventinal RFA in patients with SI jint pain r cled RFA while ne assessed the use f pulsed RFA. 51 One study cmpared cnventinal and cled RFA and it did nt reveal evidence that cled RFA f the lateral branches prvides lnger relief f sacriliac jint pain as cmpared with traditinal RFA. 52 The verall quality f evidence f all stuides was very lw. The best available evidence was in the frm f tw patient-blinded, randmized, placeb-cntrlled studies In bth f these studies, the cntrl was a sham prcedure. The remaining studies were case series: fur were prspective and six were retrspective One meta-analysis demnstrated that RFA is an effective treatment fr SI jint pain at 3 mnths and 6 mnths but this study is limited by the available literature and lack f randmized cntrlled trials. 53 Patel et al. (2012) prspectively enrlled 51 adults int a partially blinded, randmized, placeb-cntrlled study t evaluate the impact f cled RFA (neurtmy) n patients with chrnic SI jint pain. The treatment grup f 34 patients received RFA at 60 C fr 150 secnds t the L5 drsal rams and S1 t S3 lateral branches. The cntrl grup f 17 patients received placeb treatment in which n RF current was applied but the patient was subjected t sunds typical f the prcedure, injectins, and placement f electrdes. Patients in bth grups were blinded up t 3 mnths after treatment. Patients in the placeb grup were ffered crssver t treatment after the 3-mnth fllw-up. Sixteen f seventeen patients accepted the ffer t crss ver; results presented here d nt include thse frm the crssver grup. This study did nt disclse the prprtin f patients with pain relief, making it challenging t cmpare results with thse frm ther studies. The mean decrease in NRS pain scre was significantly higher in the treatment grup at 2.4 cmpared with the cntrl grup at 0.8 (P=0.035) 3 mnths after treatment. The difference was nt significant 1 mnth after treatment (P=0.16). The mean decrease in ODI scre was significantly higher in the treatment grup at 12 versus 4 (P=0.046) 1 mnth after treatment and 11 versus 2 (P=0.011) 3 mnths after treatment. A larger prprtin f patients in the treatment grup were cnsidered t have a successful utcme cmpared with thse in the cntrl grup (47% versus 12%; P=0.015) 3 mnths after treatment. Similarly, a larger percentage f patients in the treatment grup (47% versus 8%; P=0.017) reprted a psitive GPE 3 mnths after treatment. Quality f life (QOL) was marginally better in the treatment grup at versus (P=0.048). Patients reprted sreness r numbness at the treatment entry site fr up t 2 weeks after treatment. N serius cmplicatins were reprted. This study tk place at three pain management centers in the United States and was spnsred by Baylis Medical, the manufacturer f the RF generatr. 42 Page 5 f 13

6 Chen et al. (2008) enrlled 28 patients between the ages f 27 and 75 years int treatment and cntrl grups. Furteen f the patients made up the treatment grup and received RF stimulatin f 0.5 V at 75 C fr 150 secnds at the S1-S3 jints and at 80 C fr 90 secnds at the L4 and L5 jints. All patients were blinded up t 3 mnths fllwing the prcedure. Results presented here d nt include thse frm the crssver grup. The cntrl grup was subjected t the same prcedures, with the exceptin that RF electrdes were nt energized. Three mnths after the placeb prcedure, 11 f 14 patients in the placeb grup accepted the ffer t crss ver t treatment. Several utcme measures were reprted. The differences in NRS pain scre, GPE, and reductin in medicatin use were statistically significant between the treatment and placeb grups. Fr the treatment grup cmpared with the cntrl grup, mean pain scre was reprted as versus (P<0.001), respectively; the prprtin f patients with psitive GPE was 93% versus 21% (P<0.001), respectively; reductin in medicatin was 77% (10 f 14) versus 8% (1 f 11) (P<0.001), respectively. The difference in ODI scre was nt statistically significant, while the differences in success rate and duratin f pain relief between the tw grups were nt reprted. Mean ODI scre was lwer in the treatment grup at cmpared with in the cntrl grup (P<0.03). Successful utcme rate was 79% (11 f 14) in the treatment grup cmpared with 14.3% (2 f 14) (P value nt reprted) and duratin f pain relief was mnths in the treatment grup cmpared with mnths in the placeb grup (P value nt reprted). One case f transient nnpainful buttck paresthesia was reslved withut treatment. The majrity f patients experienced wrsening pain 5 t 10 days after treatment. 41 A meta-analysis was cnducted by Advin et al. (2010) t assess the effectiveness f RFA f the SI jint fr pain relief at 3 and 6 mnths after an RFA prcedure. Articles that addressed RFA f the SI jint were reviewed. Ten articles ranging frm inceptin t January 1, 2010, were fund. The main utcme measure was a reductin f pain by 50% pst-rfa prcedure. At 3 mnths, 7 grups met the criteria and at 6 mnths, 6 grups met the criteria. A meta-analysis with a frest plt was dne at the 3- and 6-mnth patient fllw-up intervals. The assciated standard errr was calculated fr each study grup. An verall weighted average with respective standard errr was als btained. A calculatin f 95% cnfidence intervals (95% CI) was then derived. A test fr hetergeneity, publicatin bias, and file drawer effect was als dne at the 3- and 6-mnth intervals. At 3 mnths, a range f was fund t have a 95% CI, with a pled mean f At 6 mnths, a 95% CI f was fund, with a pled mean f The meta-analysis demnstrated that RFA is an effective treatment fr SI jint pain at 3 mnths and 6 mnths. This study is limited by the available literature and lack f randmized cntrlled trials. Further standardizatin f RFA lesin techniques needs t be established, cupled with prspective randmized cntrlled trials. 53 SIJ Injectins There is sme evidence that intra-articular injectins f the sacriliac jint with crticsterids 17 and an anesthetic prvide relief f symptms in 33% t 93% f peple fr a perid f 1 mnth t up t 12 mnths. 1 The studies (n=14) were small, three studies were cntrlled studies n=10 t 24), and the indicatins fr treatment varied. All patients had failed cnservative drug therapy r physical therapy in ne study. The tw randmized, duble blind studies evaluating periarticular injectins demnstrated significant imprvements in pain at 1 and 2 mnths in patients with nninflammatry r inflammatry disrders f the Sacriliac jint. 2,3 Page 6 f 13

7 There are n randmised cntrlled trials evaluating the use f epidural crticsterid injectins in the pediatric ppulatin. Twelve studies investigated intra-articular injectins. One duble-blind, randmized shwed very gd r gd results in 83.3% crticsterid injectins versus 14.3% placeb injectins (p<0.05). 4 A six-mnth fllw-up shed 58% f jints remained imprved. Lng term efficacy was evaluated in eleven f the twelve studies (6 t 22 mnths) with sme degree f imprvement (33% t 93%) in 9 f the eleven. 4,6-8, N imprvement was seen in tw studies. 14,15 Evaluatin f shrt term respnse was evaluated in three f the twelve studies with imprvement suggested in tw studies 4,5 and n imprvement in the third. 14 The majrity f studies evaluated patients with spndylarthrpathy and five studies invlved patients with nninflammatry cnditins. Accrding t Hayes 1, the weight f evidence suggests that crticsterid sacriliac injectins may imprve symptms shrt and lng term but the data is nt cnclusive. Sacriliac injectins shuld be used as a cmpnent f a pain management prgram fllwing ineffective cnservative treatment and nt as a replacement fr cnventinal therapy. These injectins may lessen the demand fr the need fr mre invasive treatments 1 Tw systematic reviews f sacriliac injectins cncluded there was mderate evidence t supprt the diagnstic utility f sacriliac injectins and limited evidence fr therapeutic injectins. 18,19 The sacriliac jint is highly innervated and has been shwn t be a significant surce fr bth lw back and referred pain. There is cntrversy regarding the diagnstic and therapeutic standards fr identifying and treating sacriliac jint pain due t limited research in this area. There is n scientific evidence that histry r physical examinatin can accurately identify the sacriliac jint as a surce f pain, cntrlled sacriliac intra-articular injectins appear t be the evaluatin f chice t prvide apprpriate diagnsis f sacriliac jint pain. 20,21,23 Treatment f sacriliac jint dysfunctin typically cnsists f nn-surgical cnservative management (e.g., physical therapy, NSAIDS and ther mdalities) fr three t six mnths trying t restre nrmal jint mtin. 21 Pain management guidelines have been develped fr therapeutic sacriliac injectins fr chrnic pain unreslved by cnservative treatment measures. 21,22 Anther systematic review f diagnstic and therapeutic sacriliac injectins indicated level f evidence f II-2 (evidence was btained frm at least ne prperly designed small diagnstic accuracy study) fr the diagnsis f sacriliac jint pain utilizing cmparative, cntrlled lcal anesthetic blcks. 32 Flurscpy False-psitive rates are reprted t be apprximately 20% fr single uncntrlled sacriliac jint injectins. 25 A false-psitive injectin may ccur with extravasatin f anesthetic agent ut f the jint secndary t defects in the jint capsule. False negative results may ccur frm intravascular injectin, faulty needle placement, r inability f the lcal anesthetic agent t reach the painful prtin f the jint due t lculatins. A lw success rate between 12% and 22% has been reprted in sacriliac injectins perfrmed withut flurscpy. Blind injectins are unlikely t reach a jint space. 16 Epidural spread was seen in 24% f the patients with framinal filing nted in 44% f the patients. 25,26 A range f apprximately 95% success rate been reprted by several authrs with the use f flurscpically guided sacriliac jint injectins Page 7 f 13

8 Hayes, Cchrane, UpTDate A Hayes Medical Technlgy Directry reprt n RFA fr SIJ pain indicates that the data is insufficient t draw any definitive cnclusins abut the efficacy and safety f radifrequency ablatin (RFA) in patients with sacriliac (SI) jint pain but there is sme limited evidence that cnventinal RFA can prvide shrt-term (3 t 6 mnths) pain relief in patients wh have SI jint pain that is respnsive t injectin f lcal anesthetic. Several studies suggest that cled RFA may have a pain-relieving effect that is cmparable t that f cnventinal RFA, althugh the evidence is t sparse t supprt cnclusins abut the relative efficacy f the tw techniques. Data frm a single study f pulsed RFA are insufficient t evaluate the efficacy f this technique. 39 UpTDate: In a recent reprt n the nnsurgical interventin fr subacute and chrnic lw back pain, sacriliac injectins are mentined as a methd f treatment fr sacriliac jint pain hwever, the evidence was limited. The same reprt indicated that the evidence fr radifrequency denervatin fr presumed facet jint pain is 35 incnsistent. Prfessinal Organizatins American Sciety f Interventinal Pain Physicians (ASIPP): 1 21 ASIPP guidelines updated in 2009 suggest that sacriliac jint injectins are indicated fr patients with the fllwing: Smatic r nnradicular lw back and lwer extremity pain belw the level f L5 vertebra Duratin f pain f at least 3 mnths. Average pain levels f 6 n a scale f 0 t 10 Intermittent r cntinuus pain causing functinal disability Failure t respnd t mre cnservative management, including physical therapy mdalities with exercises, chirpractic management, and nn-steridal anti-inflammatry agents. N disc-related r facet jint pain N cntraindicatins with understanding f cnsent, nature f the prcedure, needle placement, r sedatin N histry f allergy t cntrast administratin, lcal anesthetics, sterids, Sarapin, r ther drugs ptentially utilized Cntraindicatins r inability t underg physical therapy, chirpractic management, r inability t tlerate nnsteridal anti-inflammatry drugs. Fr therapeutic sacriliac jint interventins with intraarticular injectins r radifrequency neurtmy, the jint shuld have been psitive utilizing cntrlled diagnstic blcks American Sciety f Anesthesilgists (ASA): The practice guidelines fr chrnic pain management indicate that 1, 31 Sacriliac jint injectins may be cnsidered fr symptmatic relief f sacriliac jint pain. American Sciety f Anesthesilgists (ASA) / American Sciety f Reginal Anesthesia and Pain Medicine (ASRA): In their Practice Guidelines fr Chrnic Pain Management, the ASA Task Frce n Chrnic Pain Page 8 f 13

9 Management and ASRA in cnjunctin with cnsultants state that cnventinal r thermal RFA f the medial branch nerves shuld be perfrmed fr lw back (medial branch) pain nly after diagnstic r therapeutic injectins f the jint r medial branch nerve have prvided temprary relief. The task frce recmmends the use f water-cled RFA fr chrnic SI jint pain, althugh the members f ASA and ASRA were equivcal n its use fr this applicatin. The Task Frce recmmends that neurablative prcedures shuld be used as part f a cmprehensive pain management regimen, perfrmed nly as a last resrt when pain is refractry t ther therapies. 40 CODING INFORMATION: THE CODES LISTED IN THIS POLICY ARE FOR REFERENCE PURPOSES ONLY. LISTING OF A SERVICE OR DEVICE CODE IN THIS POLICY DOES NOT IMPLY THAT THE SERVICE DESCRIBED BY THIS CODE IS A COVERED OR NON-COVERED. COVERAGE IS DETERMINED BY THE BENEFIT DOCUMENT. THIS LIST OF CODES MAY NOT BE ALL INCLUSIVE. CPT Descriptin Injectin prcedure fr sacriliac jint, anesthetic/sterid, with image guidance (flurscpy r CT) including arthrgraphy when perfrmed 0216T 0217T 0218T Injectin(s), diagnstic r therapeutic agent, paravertebral facet (zygapphyseal) jint (r nerves innervating that jint) with ultrasund guidance, lumbar r sacral; single level Injectin(s), diagnstic r therapeutic agent, paravertebral facet (zygapphyseal) jint (r nerves innervating that jint) with ultrasund guidance, lumbar r sacral; secnd level (List separately in additin t cde fr primary prcedure) Injectin(s), diagnstic r therapeutic agent, paravertebral facet (zygapphyseal) jint (r nerves innervating that jint) with ultrasund guidance, lumbar r sacral; third and any additinal level(s) (List separately in additin t cde fr primary prcedure) Destructin by neurlytic agent, paravertebral facet jint nerve; lumbar r sacral, single level Destructin by neurlytic agent, paravertebral facet jint nerve; lumbar r sacral, each additinal level Destructin by neurlytic agent, ther peripheral nerve r branch (when specified as lateral branch blck) Unlisted prcedure, nervus system [when specified as pulsed radifrequency] HCPCS Descriptin N/A ICD-9 Descriptin: [Fr dates f service prir t 10/01/2015] Chrnic pain (use in additin t identify as chrnic ) Ankylsing spndylitis Page 9 f 13

10 720.2 Sacriliitis, nt elsewhere classified Lumbsacral facet jint arthrpathy, arthritis, spndylsis Lumbsacral degenerative disc disease Lw back pain Sacriliac pain, Sacriliac disease, Disrders f sacrum Lwer extremity pain Sacriliac jint dysfunctin Debility in cnjunctin with ther listed cdes Sprains and strains f sacriliac regin Sprains and strains f sacriliac regin, Other specified sites f sacriliac regin Sprains and strains f sacriliac regin, Unspecified site f sacriliac regin ICD-10 Descriptin: [Fr dates f service n r after 10/01/2015] M08.1 Juvenile ankylsing spndylitis M45.6 Ankylsing spndylitis lumbar regin M45.7 Ankylsing spndylitis lumbsacral regin M45.8 Ankylsing spndylitis sac and sacrcccygeal regin M48.8x6 M48.8x7 M48.8x8 Other spec spndylpathies lumbar rgn Other spec spndylpathies lumbscaral regin Other spndylpathies sac & sacrcccygeal regins M46.1 Sacrilitis nt elsewhere classified M43.27 Fusin f spine lumbsacral regin M43.28 Fusin spine sacral & sacrcccygeal rgn M53.2x7 M53.2x8 Spinal instabilities lumbsacral regin Spinal instabilities sac & sacrcccygeal regin M53.3 Sacrcccygeal disrders nec M53.86 Other spec drspathies lumbar regin M53.87 Other spec drspthies lumbsacral rgn Page 10 f 13

11 M53.88 Oth spec drspathies sac sacrcccygeal regins S33.8xxA S33.6xxA S33.8xxA S33.8xxA S33.8xxA S33.9xxA Sprain ther parts lumbar spine & pelvis Initial encunter Sprain sacriliac jint, init enc Sprain ther parts lumbar spine & pelvis Initial encunter Sprain ther parts lumbar spine & pelvis Initial encunter Sprain ther parts lumbar spine & pelvis Initial encunter Sprain unspecified parts lumbar spine & pelvis init enc RESOURCE REFERENCES 1. Hayes, Inc. Hayes Brief. Sacriliac jint injectins with crticsterids fr treatment f chrnic lw back pain. Lansdale, PA: Hayes, Inc.; March 24, Archived April, Luukkainen R, Nissila M, Asikainen E. Periarticular crticsterid treatment f the sacriliac jint in patients with sernegative spndylarthpathy. Clinical Exp Rheumatlgy. 1999;17(1): Luukkainen RK, Wennerstrand PV, Kautiainen HH et al. Efficacy f periarticular crticsterid treatment f the sacriliac jint in nn-spndylarthrpathic patients with chrnic lw back pain in the regin f the sacriliac jpint. Clin Exp. Rheumatlgy 2002;20(1): Maugars, Y., Mathis, C., Berthelt, JM., Charlier, C., Prst, A. (1996). Assessment f the efficacy f sacriliac crticsterid injectins in spndylarthrpsthies: a duble-blind study. British Jurnal f Rheumatlgy. (35) 8: Karabacakglu A, Karak se S, Ozerbil OM, Odev K. Flurscpy -guided intraarticular crticsterid injectin int the sacriliac jints in patients with ankylsing spndylitis. Acta Radil. 2002;43(4): Bllw M, Braun J, Taupitz M, et al. CT-guided intraarticular crticsterid injectin int the sacriliac jints in patients with spndylarthrpathy: indicatin and fllw-up with cntrast-enhanced MRI. J Cmput Assist Tmgr. 1996;20(4): Braun J, Bllw M, Seyrekbasan F, et al. Cmputed tmgraphy guided crticsterid injectin f the sacriliac jint in patients with spndylarthrpathy with sacriliitis: clinical utcme and fllwup by dynamic magnetic resnance imaging. J Rheumatl. 1996;23(4): G naydin I, Pereira PL, Daikeler T, et al. Magnetic resnance imaging guided crticsterid injectin f the sacriliac jints in patients with therapy resistant spndylarthrpathy: a pilt study. J Rheumatl. 2000;27(2): Pereira PL, G naydin I, Tr benbach J, et al. Interventinal MR imaging fr injectin f sacriliac jints in patients with sacriliitis. AJR Am J Rentgenl. 2000;175(1): G naydin I, Pereira PL, Fritz J, et al. Magnetic resnance imaging guided crticsterid injectin f sacriliac jints in patients with spndylarthrpathy. Are multiple injectins mre beneficial? Rheumatl Int. 2006;26(5): Maugars Y, Mathis C, Viln P, Prst A. Crticsterid injectin f the sacriliac jint in patients with sernegative spndylarthrpathy. Arthritis Rheum. 1992;35(5): Slipman CW, Lipetz JS, Plastaras CT, et al. Flurscpically guided therapeutic sacriliac jint injectins fr sacriliac jint syndrme. Am J Phys Med Rehabil. 2001;80(6): Chakraverty R, Dias R. Audit f cnservative management f chrnic lw back pain in a secndary care setting-part I: facet jint and sacriliac jint interventins. Acupunct Med. 2004;22(4): Pulisetti D, Ebraheim NA. CT-guided sacriliac jint injectins. J Spinal Disrd. 1999;12(4): Hanly JG, Mitchell M, MacMillan L, et al. Efficacy f sacriliac crticsterid injectins in patients with inflammatry spndylarthrpathy: Results f a 6 mnth cntrlled study. J Rheumatl. 2000;27(3): Frst, S.L., Wheeler, M.Y., Frtin, J.D., and Vilensky, J.A. (2006) The sacriliac jint: anatmy, physilgy and clinical significance. Pain Physician. 9: Retrieved n May 15, 2007 frm: Page 11 f 13

12 17. Levin JH. Prspective-duble-blind, randmized placeb-cntrlled trials in interventinal spine: what the highest quality literature tells us. The Spine Jurnal (2009);9: Hansen, H.C., (2007). Sacriliac Jint Interventin: A systematic review. Pain Physician Jurnal. 2007;10(1): Bswell, M.V., Tresctt, A.M., Datta, S., et al. (2007). Interventinal techniques: Evidence-based practice guidelines in the management f chrnic spinal pain.10: Byajian, S.S. (2005) Interventinal pain management: an verview fr primary care physicians. Jurnal f the American Ostepathic Assciatin. September, 2005 (105) 9: Manchikanti L, Bswell MV, Singh V et al. Cmprehensive evidence based guidelines fr interventinal techniques in the management f chrnic spinal pain. Pain Physician 2009;12: Accessed May 2012 at: Manchikanti L, Helm S, Singh V et al. An algrithmic apprach fr clinical management f chrnic spinal pain. Pain Physician 2009;12:E225-E Rubinstein SM, van Tulder M. A best-evidence review f diagnstic prcedures fr neck and lw-back pain. Best PractRes Clin Rheumatl 2008; 22: Nvitas Slutins, Inc. LCD L Paravertebral Facet Jint Nerve Blck and Sacriliac Jint Injectin. Accessed July 2012 at: dlkup=title&keywrdsearchtype=and&bc=gaaaaaaaaaaa&=& 25. Hansen HC. Is Flurscpy Necessary fr Sacriliac Jint Injectins? Pain Physician. 2003;6: , ISSN Rsenberg JM, Quint TJ, de Rsayr AM. Cmputerized tmgraphic lcalizatin f clinically-guided sacriliac jint injectins. Clin J Pain 2000; 16: Schwarzer AC, Aprill CN, Bgduk M. The sacriliac jint in chrnic lw back pain. Spine 1995; 20: Laslett M, Yung SB, Aprill CN, McDnald B. Diagnsing painful sacriliac jints: A validity study f a McKenzie evaluatin and sacriliac prvcatin tests. Aust J Physither 2003; 49: Dreyfuss P, Michaelsen M, Pauza K, McLarty J, Bgduk N. The value f medical histry and physical examinatin in Msdiagnsing sacriliac jint pain. Spine 1996; 21: Dussault RG, Kaplan PA, Andersn MW. Flurscpy-guided sacriliac jint injectins. Radilgy 2000;214: May 2012 Update: 31. American Sciety f Anesthesilgists (ASA) Practice guidelines fr chrnic pain management. An Updated reprt by the American Sciety f Anesthesilgists Task Frce n Pain Management, Chrnic Pain Sectin. Anesthesilgy. 2010; 112: Rupert MP, Lee M, Manchikanti L et al. Evaluatin f sacriliac jint interventins: a systematic appraisal f the literature. Pain Physician 2009; 12(2): Accessed May 2012 at: Manchikanti L, Datta S, Gupta S et al. A Critical Review f the American Pain Sciety Clinical Practice Guidelines Fr Interventinal Techniques: Part 2 Therapeutic Interventins. Pain Physician Jul-Aug;13(4):E Accessed May 2012 at: Chu R, Atlas SJ et al. Nnsurgical interventinal therapies fr lw back pain: a review f the evidence fr an American Pain Sciety clinical practice guideline. Spine May 1;34(10): UpTDate. Chu R. Subacute and chrnic lw back pain: Nnsurgical interventinal treatment. Literature current thrugh April Gupta S. Duble needle technique: an alternative methd fr perfrming difficult sacriliac jint injectins. Pain Physician May-Jun;14(3): Accessed May 2012 at: CMS First Cast Service Optins. LCD #L29274 fr Sacriliac Jint Injectins. Updated Jan Accessed at: dlkup=title&keywrdsearchtype=and&bc=gaaaaaaaaaaa&=& 38. Advanced Medical Review (AMR): Plicy reviewed by MD bard certified in Physical Medicine & Rehab, Pain Medicine. August 13, 2012 Page 12 f 13

13 2013 Update Plicy reviewed and apprved by Dr. Gary Call, MD, MHI 12/11/ Update 39. Hayes Medical Technlgy Directry. Radifrequency Ablatin fr Sacriliac Jint Pain. Winifred Hayes Inc. Lansdale, PA. Aug 13, Rsenquist R, Benzn H, Cnnis R, De Len-Casasla O, Glass D. Practice guidelines fr chrnic pain management: an updated reprt by the American Sciety f Anesthesilgists Task Frce n Chrnic Pain Management and the American Sciety f Reginal Anesthesia and Pain Medicine. Anesthesilgy. 2010;112(4): Chen SP, Hurley RW, Buckenmaier CC 3rd, Kurihara C, Mrland B, Dragvich A. Randmized placeb-cntrlled study evaluating lateral branch radifrequency denervatin fr sacriliac jint pain. Anesthesilgy. 2008;109(2): Patel N, Grss A, Brwn L, Gekht G. A randmized, placeb-cntrlled study t assess the efficacy f lateral branch neurtmy fr chrnic sacriliac jint pain. Pain Med. 2012;13(3): Chen SP, Abdi S. Lateral branch blcks as a treatment fr sacriliac jint pain: a pilt study. Reg Anesth Pain Med. 2003;28(2): Gevargez A, Grenemeyer D, Schirp S, Braun M. CT-guided percutaneus radifrequency denervatin f the sacriliac jint. Eur Radil. 2002;12(6): Yin W, Willard F, Carreir J, Dreyfuss P. Sensry stimulatin-guided sacriliac jint radifrequency neurtmy: technique based n neuranatmy f the drsal sacral plexus. Spine (Phila Pa 1976). 2003;28(20): Speldewinde GC. Outcmes f percutaneus zygapphysial and sacriliac jint neurtmy in a cmmunity setting. Pain Med. 2011;12(2): Buijs EJ, Kamphuis ET, Gren GJ. Radifrequency treatment f sacriliac jint-related pain aimed at the first three sacral drsal rami: a minimal apprach. Pain Clinic. 2004;16: Chen SP, Strassels SA, Kurihara C, et al. Outcme predictrs fr sacriliac jint (lateral branch) radifrequency denervatin. Reg Anesth Pain Med. 2009;34(3): Kapural L, Nageeb F, Kapural M, Cata JP, Naruze S, Mekhail N. Cled radifrequency system fr the treatment f chrnic pain frm sacriliitis: the first case-series. Pain Pract. 2008;8(5): Karaman H, Kavak GO, T fek A, et al. Cled radifrequency applicatin fr treatment f sacriliac jint pain. Acta Neurchirurgica. 2011;153(7): Vallej R, Benyamin RM, Kramer J, Stantn G, Jseph NJ. Pulsed radifrequency denervatin fr the treatment f sacriliac jint syndrme. Pain Med. 2006;7(5): Cheng J, Ppe JE, Daltn JE, Cheng O, Bensitel A. Cmparative utcmes f cled versus traditinal radifrequency ablatin f the lateral branches fr sacriliac jint pain. Clin J Pain Epub ahead f print. June 7, Available at: Accessed August 17, Aydin SM1, Gharib CG, Mehnert M, Stitik TP. The rle f radifrequency ablatin fr sacriliac jint pain: a meta-analysis. PM R Sep;2(9): di: /j.pmrj Official Disability Guidelines (ODG). Sacriliac Jint Blcks. June 10, Page 13 f 13