POLICY PRODUCT VARIATIONS DESCRIPTION/BACKGROUND RATIONALE DEFINITIONS BENEFIT VARIATIONS DISCLAIMER CODING INFORMATION REFERENCES POLICY HISTORY

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1 Original Issue Date (Created): February 28, 2012 Most Recent Review Date (Revised): May 20, 2014 Effective Date: August 13, 2014 POLICY PRODUCT VARIATIONS DESCRIPTION/BACKGROUND RATIONALE DEFINITIONS BENEFIT VARIATIONS DISCLAIMER CODING INFORMATION REFERENCES POLICY HISTORY I. POLICY Sacroiliac Joint Arthrography Arthrography of the sacroiliac joint is considered investigational. There is insufficient evidence to support a conclusion concerning the health outcomes or benefits associated with this procedure. Sacroiliac Joint Injections Sacroiliac joint medication injections may be considered medically necessary for pain lasting more than three months despite appropriate conservative treatment. Documentation of fluoroscopy is required with each injection, to ensure correct needle placement. If successful (as documented by the usage of validated patient focused pain intensity assessment scales), it is reasonable to repeat the injection initially in two to four months. It is not medically necessary to perform sacroiliac injections more than four per twelve-month period, beginning with the date of the first injection. Sacroiliac injections are considered not medically necessary for indications other than those listed above. Radiofrequency Ablation Radiofrequency ablation of the sacroiliac joint is considered investigational. There is insufficient evidence to support a conclusion concerning the health outcomes or benefits associated with this procedure. Fusion/stabilization of the Sacroiliac Joint Fusion/stabilization of the sacroiliac joint for the treatment of back pain presumed to originate from the SI joint is considered investigational, including but not limited to percutaneous and minimally invasive techniques. There is insufficient evidence to support a conclusion concerning the health outcomes or benefits associated with this procedure. Page 1

2 Cross-references: MP Radiofrequency Facet Joint Denervation MP Prolotherapy II. PRODUCT VARIATIONS [N] = No product variation, policy applies as stated [Y] = Standard product coverage varies from application of this policy, see below [N] Capital Cares 4 Kids [N] PPO [N] HMO [Y] SeniorBlue HMO* [Y] SeniorBlue PPO* [N] Indemnity [N] SpecialCare [N] POS [Y] FEP PPO** *Refer to Novitas Solutions Local Coverage Determination (LCD) L27512 Transforaminal Epidural, Paravertebral Facet and Sacroiliac Joint Injections. ** For Sacroiliac Joint Arthrography and Injection, refer to FEP Medical Policy Manual MP Sacroiliac Joint Arthrography and Injection. The FEP Medical Policy manual can be found at: III. DESCRIPTION/BACKGROUND Sacroiliac joint arthrography using fluoroscopic guidance with injection of an anesthetic has been explored as a diagnostic test for sacroiliac joint pain. Duplication of the patient s pain pattern with the injection of contrast medium suggests a sacroiliac etiology, as does relief of chronic back pain with injection of local anesthetic. Similar to other structures in the spine, it is assumed that the sacroiliac joint may be a source of low back pain. In fact, prior to 1928, the sacroiliac joint was thought to be the most common cause of sciatica. In 1928, the role of the intervertebral disc was elucidated, and from that point forward the sacroiliac joint received less research attention. Research into sacroiliac joint pain has been thwarted by any criterion standard to measure its prevalence and against which various clinical examinations can be validated. For example, sacroiliac joint pain is typically without any consistent, demonstrable radiographic or laboratory features and most commonly exists in the setting of morphologically normal joints. Clinical tests for sacroiliac joint pain may include various movement tests, palpation to detect tenderness, and pain descriptions by the patient. Further confounding the study of the sacroiliac joint is that multiple structures, such as posterior facet joints and lumbar discs, may refer pain to the area surrounding the sacroiliac joint. Page 2

3 Because of inconsistent information obtained from history and physical examination, some have proposed the use of image-guided anesthetic injection into the sacroiliac joint for the diagnosis of sacroiliac joint pain. Treatments being investigated for sacroiliac joint pain include prolotherapy corticosteroid injection, and radiofrequency ablation. Regulatory Status A number of radiofrequency generators and probes have been cleared for marketing through the U.S. Food and Drug Administration s (FDA) 510(k) process. One device, the SInergy by Kimberly Clark/Baylis, is a water-cooled single-use probe that received FDA clearance in 2005, listing the Baylis Pain Management Probe as a predicate device. The intended use is in conjunction with a radiofrequency generator to create radiofrequency lesions in nervous tissue. Several percutaneous or minimally invasive fixation/fusion devices have received marketing clearance by the FDA. These include the SI-FIX Sacroiliac Joint Fusion System (Medtronic), the IFUSE Implant System (SI Bone), the SImmetry Sacroiliac Joint Fusion System (Zyga Technologies) and the SI-LOK (Globus Medical). IV. RATIONALE Diagnosis The use of diagnostic blocks to evaluate sacroiliac joint pain builds on the experience of use of diagnostic blocks in other joints to evaluate pain. Blinded studies with placebo controls (although difficult to conduct when dealing with invasive procedures) are ideally required for scientific validation of sacroiliac joint blocks, particularly when dealing with pain relief wellknown to respond to placebo controls. In the typical evaluation of a diagnostic test, the results of sacroiliac diagnostic block would then be compared to a gold standard. However, there is no current gold standard for sacroiliac joint injection. In fact, some authors have positioned sacroiliac joint injection as the gold standard, against which other diagnostic tests and physical exam may be measured. (1) Finally, one would like to know how the results of a diagnostic test will be used in the management of the patient and whether the subsequent treatment plan results in beneficial health outcomes. At the time this policy was created, there was minimal literature regarding sacroiliac joint blocks. For example, Schwarzer and colleagues reported on a case series of 43 patients with unexplained low back pain below L5-S1. (2) These 43 patients were chosen opportunistically from a larger group of patients referred for discography or zygapophyseal joint blocks. Thus all patients underwent multiple procedures. A total of 13 of the 43 patients (30%) reported relief of their pain with sacroiliac joint blocks. There were no blinded controls, although the authors felt that the use of pain blocks at the zygapophyseal joints functioned as internal controls. Maigne and colleagues reported on a series of 54 patients with low back pain who received double sacroiliac joint block. (3) The first block used lidocaine, a short-acting anesthetic. If the patient reported pain relief, a second, confirmatory block was performed 1 week later using a long-acting anesthetic. If similar relief was obtained with the second block, it was concluded that the sacroiliac joint was the source of the pain. A total of 18% of patients Page 3

4 met these criteria. Similar to the Schwarzer et al. study, this study was primarily designed to demonstrate that sacroiliac pain exists and to assess its prevalence. No studies were identified that described how the results of sacroiliac joint arthrography might be used in the management of the patient. In 2007, the American Society of Interventional Pain Physicians (ASIPP) published a systematic review and Practice Guidelines, including sacroiliac joint interventions. (4, 5) Evidence was determined to be moderate (level III, non-randomized comparative trials) for the accuracy of sacroiliac joint diagnostic injections for the diagnosis of sacroiliac joint pain. The authors report that even though short-term relief from sacroiliac joint injection is considered as a gold standard for the diagnosis of sacroiliac joint pain, there was no blinded comparison of the test or reference standard in evaluation of these investigations. The evidence for intraarticular sacroiliac joint injections for short- and long-term relief was found to be limited (level IV, case series). In 2009, ASIPP based their updated guideline on a systematic review of sacroiliac injections by Rupert et al. (6, 7) This systematic review included 13 studies utilizing fluoroscopically guided controlled diagnostic blocks (i.e., placebo-controlled or comparative local anesthetic) in patients with chronic low back and/or lower extremity pain for greater than 3 months duration. Five studies, considered level II-2 evidence (well-designed cohort or case-control studies), were reviewed on the topic of diagnosis of sacroiliac joint pain using a double-block paradigm (comparative controlled local anesthetic blocks). The false-positive rate for use of a single, uncontrolled, sacroiliac joint injection was 20% to 54%. With a double-block paradigm, the prevalence of sacroiliac joint pain was estimated to range between 10% and 38% in patients with a high likelihood of sacroiliac joint pain. Interpretation of these results is limited by the lack of a gold standard for reference comparison. ASIPP concluded that sacroiliac joint blocks appear to be the evaluation of choice to provide appropriate diagnosis, due to the inability to make the diagnosis of sacroiliac joint-mediated pain with noninvasive tests. (6) For therapeutic intra-articular sacroiliac joint interventions, 4 randomized trials were excluded from review due to a lack of a valid diagnosis prior to therapeutic interventions. None of the 14 observational reports met the inclusion criteria, due to lack of controlled diagnostic blocks to establish diagnosis, evaluating only patients with spondyloarthropathy, or not following patients for 6 months. Limitations were noted as a paucity of literature evaluating the role of both diagnostic and therapeutic interventions and widespread methodologic flaws practice guidelines from the American Pain Society (APS) were based on a systematic review that was commissioned by the APS and conducted at the Oregon Evidence-Based Practice Center. (8, 9) The systematic review concluded that no reliable evidence existed to evaluate validity or utility of diagnostic sacroiliac joint block as a diagnostic procedure for low back pain with or without radiculopathy, with a resulting guideline recommendation of insufficient evidence. Data on sacroiliac joint steroid injection were limited to 1 small controlled trial, resulting in a recommendation of insufficient evidence for therapeutic injection of this joint. In 2010, Manchikanti and colleagues published critical reviews of the APS guidelines for interventional techniques, including sacroiliac injections. (10, 11) Page 4

5 Evidence for diagnostic sacroiliac injections was considered to be fair to poor, and no additional literature was identified since the 2009 systematic review by Rupert and colleagues. (7) Treatment Hansen et al. published an updated systematic review of sacroiliac joint interventions in (12) The primary outcome was short-term (<6 months) or long-term (>6 months) pain relief. Evidence was classified as good, fair, or limited/poor based on the quality of evidence. A total of 11 studies (6 randomized and 5 non-randomized) met inclusion criteria. Review found that evidence for intra-articular steroid injections is limited/poor, as is the evidence for periarticular injections (local anesthetic and steroid or botulinum toxin). For radiofrequency neurotomy, the evidence for cooled radiofrequency was found to be fair (2 randomized controlled trials [RCTs]), while evidence for conventional radiofrequency or pulsed radiofrequency was limited/poor. Therapeutic Sacroiliac Injections The available literature on therapeutic sacroiliac injections is limited, consisting of one small RCT that compared steroid injections with prolotherapy, and case series. (12) There are no RCTs that compare therapeutic sacroiliac injections with placebo to determine the efficacy above placebo. Kim and colleagues reported a randomized, double-blind, controlled trial of intra-articular prolotherapy (see policy No ) compared with steroid injection for sacroiliac joint pain in (13) The study included 48 patients with sacroiliac joint pain, confirmed by 50% or greater improvement in response to a single local anesthetic block, who had failed medical treatment. Intra-articular dextrose water prolotherapy or steroid injections were administered under fluoroscopic guidance on a biweekly schedule, with a maximum of 3 injections. Injections were stopped when pain relief was 90% or greater, which required a mean of 2.7 prolotherapy injections and 1.5 steroid injections. Pain (numerical rating scale) and disability scores (Oswestry Disability Index, ODI) were assessed at baseline, 2 weeks, and monthly after completion of treatment. At 2-week follow-up, pain and disability scores were significantly improved in both groups, with no significant difference between the groups. Pain on the numerical rating scale improved from 6.3 to 1.4 in the prolotherapy group and from 6.7 to 1.9 in the steroid group. At 6 months after treatment, 63.6% of patients in the prolotherapy group remained improved from baseline (>50%), compared with 27.2% in the steroid group. At 15- month follow-up, the cumulative incidence of sustained pain relief was 58.7% in the prolotherapy group compared with 10.2% in the steroid group. The median duration of survival (recurrence of severe sacroiliac joint pain) was 3 months for the steroid group. Results from this small trial are insufficient to permit conclusions regarding the effect of this procedure on health outcomes. Comparisons to placebo, ideally using sham injections, are needed to determine the degree of benefit over placebo. In 2007 Weksler et al. reported results of diagnostic/therapeutic blocks in a series of patients who were referred for low back pain and disc herniation without claudication or neurologic Page 5

6 abnormalities. (14) Fifty patients who had at least 3 positive pain provocation tests for sacroiliac joint dysfunction received sacroiliac injection of bupivacaine and betamethasone. Pain, assessed by visual analogue scores (VAS), improved from 7.8 to 1.3 at 30 minutes after the injection. At a 12-week follow-up, 46 patients (92%) reported VAS scores of 3 or less. Four patients required hospitalization for an unanticipated motor block. Questions also remain about intra-articular versus peri-articular sources of sacroiliac pain. For example, one prospective comparison found that peri-articular lidocaine injections (25 of 25 patients) were more effective than intra-articular injection (9 of 25 patients). (15) Radiofrequency Denervation Aydin et al. published a meta-analysis of radiofrequency ablation (RFA) for sacroiliac pain in (16) Nine studies were included that reported the primary outcome measure of a reduction of pain of 50% or greater, including 1 randomized placebo controlled study, 3 prospective observational studies, and 5 retrospective studies. All of the studies used injection of local anesthetic to determine if RFA was indicated for the patient. Seven studies reported follow-up to 3 months, and 6 studies reported follow-up to 6 months. Meta-analysis indicated that half or greater of the patients who received RFA to the sacroiliac joint showed a reduction in their pain of 50% or more at 3 and 6 months. Analysis found no evidence of publication bias, but heterogeneity in studies was observed for the 6-month follow-up. This systematic review is limited by the low quality of included studies and lack of RCTs. In addition, as noted by the authors, no standards have been established for the specific nerves to ablate or type of technique. Two small RCTs were identified for this literature review. The first was published in 2008 and was the single RCT included in the systematic review. This study examined the effect of lateral branch radiofrequency denervation with a cooled probe in 28 patients with injectiondiagnosed sacroiliac joint pain. (17) Two of 14 patients (14%) in the placebo-control group reported pain relief at 1-month follow-up. None reported benefit at 3-month follow-up. Of the 14 patients treated with radiofrequency denervation, 11 (79%) reported pain relief at 1 month, 9 (64%) at 3 months, and 8 (57%) at 6 months. In 2012, Patel et al. reported a randomized double-blind placebo-controlled trial of lateral branch neurotomy with a cooled radiofrequency probe. (18) Fifty-one patients who had a positive response to 2 lateral branch blocks were randomized in a 2:1 ratio to lateral branch radiofrequency or sham. At 3-month follow-up, significant improvements in pain (-2.4 vs ), physical function (14 vs. 3), disability (-11 vs. 2), and quality of life (0.09 vs. 0.02) were observed for radiofrequency treatment compared to controls (all respectively). With treatment success defined as a 50% or greater reduction in the numerical rating scale (NRS), 47% of radiofrequency-treated patients and 12% of sham patients achieved treatment success. The treatment response was durable out to 9 months. Arthrodesis The literature on arthrodesis (open or minimally invasive) for sacroiliac joint pain consists of case series. No randomized trials were identified. Page 6

7 In 2010, Ashman et al. conducted a systematic review to compare fusion vs. denervation for chronic sacroiliac pain. (19) Six articles on fusion (95 patients) and 5 on denervation (68 patients) were included in the review. All studies on fusion were case series evaluating a single treatment. There were 2 small RCTs on radiofrequency denervation; one is described above, (17), and the other had only 9 patients. The strength of the evidence was considered to be very low to low, preventing conclusions regarding the comparative efficacy of the treatments. In 2008, Wise and Dall reported a small prospective series of 13 consecutive patients (19 joints) with sacroiliac joint pain diagnosed by a single block and treated with percutaneously inserted fusion cages filled with bone morphogenetic protein (Medtronic). (20) At 6-month follow-up, radiographs showed a fusion rate of 89% (17/19). At 24-month follow-up, there were significant improvements in VAS for back pain (improvement of 4.9 out of 10), leg pain (2.4) and dyspareunia (2.6). Two series were reported in 2012 on the ifuse Implant System for minimally-invasive fusion of the sacroiliac joint. A study by Sachs and Capobianco reported mean VAS for pain of 7.9 at baseline and 2.3 at 12-month follow-up for a series of 11 consecutive patients. (21) Rudolf reported a retrospective analysis of his first 50 consecutive patients. (22) There were 10 perioperative complications, including implant penetration into the sacral neural foramen (2 patients) and compression of the L5 nerve (1 patient); these resolved with surgical retraction of the implant. At a minimum of 24 months follow-up (mean of 40 months), the treating surgeon was able to contact 45 patients. The mean pain score was 2, and 82% of patients had attained the minimum clinically important difference (MCID, defined as >2 out of 10). Clinical Input Received through Physician Specialty Societies and Academic Medical Centers While the various physician specialty societies and academic medical centers may collaborate with and make recommendations during this process through the provision of appropriate reviewers, input received does not represent an endorsement or position statement by the physician specialty societies or academic medical centers, unless otherwise noted. In response to requests, input was received from 4 physician specialty societies (6 responses) and 3 academic medical centers (5 responses) while this policy was under review in Clinical input was mixed. There was general agreement that the evidence for sacroiliac joint injections is limited, although a majority of reviewers considered sacroiliac injections to be the best available approach for diagnosis and treatment in defined situations. Summary There is limited prospective or controlled evidence for sacroiliac joint arthrography, injection therapy, radiofrequency ablation (RFA) or fixation/fusion. For radiofrequency ablation, there are two small RCTs that report short-term benefit, but these are insufficient to determine the overall effect on health outcomes. Further high-quality controlled trials are needed that compare specific procedures in defined populations to placebo and to alternative treatments. Page 7

8 Case series are inadequate evidence due to the variable natural history of back pain, the presence of confounders of outcome, and the potential for a placebo effect. In general, the literature regarding injection therapy on joints in the back is of poor quality. The current evidence on sacroiliac joint arthrography, injections, RFA, and fixation/fusion is insufficient to permit conclusions regarding the effect of these procedures on health outcomes. Therefore, these techniques are considered investigational for the diagnosis and treatment of sacroiliac joint pain. Practice Guidelines and Position Statements The ASIPP Interventional Pain Management guidelines were updated in The guidelines for diagnostic and therapeutic sacroiliac joint injections were based on the systematic review by Manchikanti et al. and Rupert et al. described earlier. (6, 7) Evidence for sacroiliac joint injections was considered to be level II-2 (evidence obtained from at least 1 properly designed small diagnostic accuracy study). The guidelines indicate that sacroiliac joint blocks appear to be the evaluation of choice to provide appropriate diagnosis, due to the inability to make the diagnosis of sacroiliac joint-mediated pain with non-invasive tests. Evidence was determined to be unavailable to establish efficacy of intra-articular sacroiliac joint injections for therapeutic purposes. Common indications for sacroiliac joint injections were listed as follows: Somatic or nonradicular low back and lower extremity pain below the level of L5 vertebra. Duration of pain of at least 3 months. Average pain levels of >6 on a scale of 0 to 10. Intermittent or continuous pain causing functional disability. Failure to respond to more conservative management, including physical therapy modalities with exercises, chiropractic management, and non-steroidal anti-inflammatory agents. Lack of obvious evidence for disc-related or facet joint pain. No contraindications with understanding of consent, nature of the procedure, needle placement, or sedation. No history of allergy to contrast administration, local anesthetics, steroids, Sarapin, or other drugs potentially utilized. Contraindications or inability to undergo physical therapy, chiropractic management, or inability to tolerate non-steroidal anti-inflammatory drugs. For therapeutic sacroiliac joint interventions with intra-articular injections or radiofrequency neurotomy, the joint should have been positive utilizing controlled diagnostic blocks. Recommended frequency of interventions was also described. The 2009 practice guidelines from the APS were based on a systematic review that was commissioned by the APS and conducted at the Oregon Evidence-Based Practice Center. (8, 9) The APS guideline states that there is insufficient evidence to evaluate validity or utility of diagnostic sacroiliac joint block as a diagnostic procedure for low back pain with or without Page 8

9 radiculopathy and that there is insufficient evidence to adequately evaluate benefits of sacroiliac joint steroid injection for nonradicular low back pain. V. DEFINITIONS ARTHROGRAPHY is a diagnostic study that involves the injection of contrast media into a joint. VI. BENEFIT VARIATIONS The existence of this medical policy does not mean that this service is a covered benefit under the member's contract. Benefit determinations should be based in all cases on the applicable contract language. Medical policies do not constitute a description of benefits. A member s individual or group customer benefits govern which services are covered, which are excluded, and which are subject to benefit limits and which require preauthorization. Members and providers should consult the member s benefit information or contact Capital for benefit information. VII. DISCLAIMER Capital s medical policies are developed to assist in administering a member s benefits, do not constitute medical advice and are subject to change. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any medical policy related to their coverage or condition with their provider and consult their benefit information to determine if the service is covered. If there is a discrepancy between this medical policy and a member s benefit information, the benefit information will govern. Capital considers the information contained in this medical policy to be proprietary and it may only be disseminated as permitted by law. VIII. CODING INFORMATION Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement. Page 9

10 Investigational and therefore not covered when used to report diagnosis and treatment of sacroiliac joint pain as outlined in the policy section above: CPT Codes 0334T Current Procedural Terminology (CPT) copyrighted by American Medical Association. All Rights Reserved. Medically Necessary: HCPCS Description Code G0259 G0260 INJECTION PROCEDURE FOR SACROILIAC JOINT; ARTHROGRAPHY INJ PROC SI JNT;ANES STEROID&/TX AGT&ARTHROGRPH *If applicable, please see Medicare LCD or NCD for additional covered diagnoses.. VIII. REFERENCES 1. Dreyfuss P, Michaelsen M, Pauza K et al. The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine (Phila Pa 1976) 1996; 21(22): Schwarzer AC, Aprill CN, Bogduk N. The sacroiliac joint in chronic low back pain. Spine (Phila Pa 1976) 1995; 20(1): Maigne JY, Aivaliklis A, Pfefer F. Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain. Spine (Phila Pa 1976) 1996; 21(16): Boswell MV, Trescot AM, Datta S et al. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician 2007; 10(1): Hansen HC, McKenzie-Brown AM, Cohen SP et al. Sacroiliac joint interventions: a systematic review. Pain Physician 2007; 10(1): Manchikanti L, Boswell MV, Singh V et al. Comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician 2009; 12(4): Rupert MP, Lee M, Manchikanti L et al. Evaluation of sacroiliac joint interventions: a systematic appraisal of the literature. Pain Physician 2009; 12(2): Chou R, Atlas SJ, Stanos SP et al. Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine (Phila Pa 1976) 2009; 34(10): Page 10

11 9. Chou R, Loeser JD, Owens DK et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine (Phila Pa 1976) 2009; 34(10): Manchikanti L, Datta S, Derby R et al. A critical review of the American Pain Society clinical practice guidelines for interventional techniques: part 1. Diagnostic interventions. Pain Physician 2010; 13(3):E Manchikanti L, Datta S, Gupta S et al. A critical review of the American Pain Society clinical practice guidelines for interventional techniques: part 2. Therapeutic interventions. Pain Physician 2010; 13(4):E Hansen H, Manchikanti L, Simopoulos TT et al. A systematic evaluation of the therapeutic effectiveness of sacroiliac joint interventions. Pain Physician 2012; 15(3):E Kim WM, Lee HG, Jeong CW et al. A randomized controlled trial of intra-articular prolotherapy versus steroid injection for sacroiliac joint pain. J Altern Complement Med 2010; 16(12): Weksler N, Velan GJ, Semionov M et al. The role of sacroiliac joint dysfunction in the genesis of low back pain: the obvious is not always right. Arch Orthop Trauma Surg 2007; 127(10): Murakami E, Tanaka Y, Aizawa T et al. Effect of periarticular and intraarticular lidocaine injections for sacroiliac joint pain: prospective comparative study. J Orthop Sci 2007; 12(3): Aydin SM, Gharibo CG, Mehnert M et al. The role of radiofrequency ablation for sacroiliac joint pain: a meta-analysis. PM R 2010; 2(9): Cohen SP, Hurley RW, Buckenmaier CC, 3rd et al. Randomized placebo-controlled study evaluating lateral branch radiofrequency denervation for sacroiliac joint pain. Anesthesiology 2008; 109(2): Patel N, Gross A, Brown L et al. A randomized, placebo-controlled study to assess the efficacy of lateral branch neurotomy for chronic sacroiliac joint pain. Pain Med 2012; 13(3): Ashman B, Norvell DC, Hermsmeyer JT. Chronic sacroiliac joint pain: fusion versus denervation as treatment options. Evid Based Spine Care J 2010; 1(3): Wise CL, Dall BE. Minimally invasive sacroiliac arthrodesis: outcomes of a new technique. J Spinal Disord Tech 2008; 21(8): Sachs D, Capobianco R. One year successful outcomes for novel sacroiliac joint arthrodesis system. Ann Surg Innov Res 2012; 6(1): Rudolf L. Sacroiliac Joint Arthrodesis-MIS Technique with Titanium Implants: Report of the First 50 Patients and Outcomes. Open Orthop J 2012; 6: Other: Novitas, Solutions Local Coverage Determination (LCD) L27512 Transforaminal Epidural, Paravertebral Facet and Sacroiliac Joint Injections Effective 04/12/12. [Website]: Page 11

12 Accessed March 7, IX. POLICY HISTORY MP CAC 11/22/11 New policy with criteria previously addressed in MP Pain Control. BCBSA guidelines adopted. Arthrography of the sacroiliac joint remains investigational. Injection into the sacroiliac joint for treatment of pain previously considered medically necessary, is now considered investigational. FEP variation added. 2/9/12- Policy title changed to Diagnosis and Treatment of Sacroiliac Joint Pain. Radiofrequency ablation of the sacroiliac joint added as investigational. 3/22/12 Decision to adopt BCBSA revised. The revisions approved 11/22/11 were not posted. Will keep current policy criteria that were in the MP Pain Control. The procedure for sacroiliac joint injection for treatment of pain will remain medically necessary. 04/22/13- Admin code review CAC 7/30/13 Minor. Statement added indicating fusion/stabilization of the sacroiliac joint for the treatment of back pain presumed to originate from the SI joint is considered investigational, including but not limited to percutaneous and minimally invasive techniques. Policy coded 04/29/2014 Added as investigational CAC 5/20/14 Consensus review. References updated. No changes to the policy statements. Rationale added. Codes reviewed. 8/12/2014 Admin error correction, code Not on Aug posting, placed again with CPT codes in accordance with language noting as investigational as per CAC 7/30/13 Top Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company, Capital Advantage Assurance Company and Keystone Health Plan Central. Independent licensees of the BlueCross BlueShield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. Page 12