BlueCross and BlueShield of Montana Medical Policy/Codes
Sacroiliac Joint Fusion or Stabilization
Chapter: Surgery: Procedures
Current Effective Date: November 26, 2013
Original Effective Date: November 26, 2013
Publish Date: August 26, 2013
Description

Similar to other structures in the spine, it is assumed that the sacroiliac joint (SIJ) may be a source of low back pain. In fact, prior to 1928, the SIJ 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 SIJ received less research attention.

Research into SIJ pain has been thwarted by any criterion standard to measure its prevalence and against which various clinical examinations can be validated. For example, SIJ 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 SIJ pain may include various movement tests, palpation to detect tenderness, and pain descriptions by the patient. Further confounding study of the SIJ is that multiple structures, such as posterior facet joints and lumbar discs, may refer pain to the area surrounding the SIJ.

Because of inconsistent information obtained from history and physical examination, some have proposed various modalities to diagnose SIJ pain. Treatments are being investigated for SIJ pain, including stabilization or fusion by arthrodesis.

Regulatory Status

Several percutaneous or minimally invasive fixation or fusion devices have received marketing clearance by the U.S. Food and Drug Administration (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).

Policy

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply.  If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Investigational

Blue Cross and Blue Shield of Montana (BCBSMT) considers sacroiliac joint (SIJ) fusion or stabilization for the treatment of back pain presumed to originate from the SIJ experimental, investigational and unproven, including but not limited to percutaneous and minimally invasive techniques.

Rationale

In a MedLine search through February 2013, the scientific literature on arthrodesis (open or minimally invasive) for sacroiliac joint (SIJ) pain consists of case series. No randomized trials were identified.

In 2010, Ashman et al. conducted a systematic review to compare fusion vs. denervation for chronic sacroiliac pain. (1) 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. 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 SIJ pain diagnosed by a single block and treated with percutaneously inserted fusion cages filled with bone morphogenetic protein (Medtronic). (2) At 6-month follow-up, radiographs showed a fusion rate of 89%. At 24-month follow-up, there were significant improvements in visual analogue scores (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 SIJ. 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. (3) Rudolf reported a retrospective analysis of his first 50 consecutive patients. (4) There were 10 peri-operative 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 (defined as >2 out of 10).

Summary

There is limited prospective or controlled evidence for SIJ fixation/fusion. The current evidence on SIJ fixation/fusion is insufficient to permit conclusions regarding the effect of these procedures on health outcomes. Therefore, these techniques are considered experimental, investigational and unproven for the treatment of SIJ pain.

Coding

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps. 

ICD-9 Codes
81.29, 720.2, 724.00, 724.01, 724.02, 724.03, 724.09, 724.1, 724.2, 724.3, 724.4, 724.5, 724.6, 724.70, 724.71, 724.79, 724.8, 724.9
ICD-10 Codes

M46.1, M47.898, M47.899, M48.0, M48.04, M48.05, M48.06, M48.07, M48.08, M54.16, M54.17, M54.30, M54.31, M54.32, M54.40, M54.41, M54.42, M54.5, M54.6, M54.89, M54.9, M62.830, 0SG 734Z, 0SG73ZZ, 0SG737Z, 0SG74JZ, 0SG73KZ, 0SG747Z, 0SG73JZ, 0SG744Z, 0SG74KZ, 0SG74ZZ, 0SG83KZ 0SG83ZZ, 0SG834Z, 0SG837Z, 0SG844Z, 0SG84ZZ, 0SG84JZ, 0SG847Z, 0SG84KZ

Procedural Codes: 27280, 0334T
References
  1. Ashman B, Norvell DC, Hermsmeyer JT. Chronic sacroiliac joint pain: fusion versus denervation as treatment options. Evid Based Spine Care J 2010; 1(3):35-44.
  2. Wise CL, Dall BE. Minimally invasive sacroiliac arthrodesis: outcomes of a new technique. J Spinal Disord Tech 2008; 21(8):579-84.
  3. Sachs D, Capobianco R. One year successful outcomes for novel sacroiliac joint arthrodesis system. Ann Surg Innov Res 2012; 6(1):13.
  4. Rudolf L. Sacroiliac Joint Arthrodesis-MIS Technique with Titanium Implants: Report of the First 50 Patients and Outcomes. Open Orthop J 2012; 6:495-502.
  5. Diagnosis and Treatment of Sacroiliac Joint Pain. Chicago, Illinois. Blue Cross Blue Shield Association Medical Policy Reference Manual (2013 February) Radiology 6.01.23.
History
August 2013  New 2013 BCBSMT medical policy.  Sacroiliac joint (SIJ) fusion or stabilization for the treatment of back pain presumed to originate from the SIJ is considered experimental, investigational and unproven, including but not limited to percutaneous and minimally invasive techniques. 
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Sacroiliac Joint Fusion or Stabilization