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.
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.
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).
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.
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.