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A recent convening of Alabama BCBS’ Medical Policy Group proposed a positive change to their policy on Minimally Invasive SI Joint Surgery to establish MIS SIJ fusion as medically necessary using an FDA-approved device (not specific to any one device type) when all of the following criteria are met:
- Pain is at least 5 on a 0 to 10 rating scale that impacts quality of life or limits activities of daily living; AND
- There is an absence of generalized pain behavior (e.g., somatoform disorder) or generalized pain disorders (e.g., fibromyalgia); AND
- Patients have undergone and failed a minimum six months of intensive non-operative treatment that must include medication optimization, activity modification, bracing, and active therapeutic exercise targeted at the lumbar spine, pelvis, sacroiliac joint, and hip, including a home exercise program; AND
- Pain is caudal to the lumbar spine (L5 vertebra), localized over the posterior sacroiliac joint, and consistent with sacroiliac joint pain; AND
- A thorough physical examination demonstrates localized tenderness with palpation over the sacral sulcus (Fortin’s point) in the absence of tenderness of similar severity elsewhere; AND
- There is a positive response to a cluster of three provocative tests (e.g., thigh thrust test, compression test, Gaenslen sign, distraction test, Patrick test, posterior provocation test); AND
- Diagnostic imaging studies include ALL of the following:
- Imaging (plain radiographs and computed tomography or magnetic resonance imaging) of the sacroiliac joint excludes the presence of destructive lesions (e.g., tumor, infection) or inflammatory arthropathy of the sacroiliac joint; AND
- Imaging of the pelvis (anteroposterior plain radiograph) rules out concomitant hip pathology; AND
- Imaging of the lumbar spine (computed tomography or magnetic resonance imaging) is performed to rule out neural compression or other degenerative conditions that can be causing low back or buttock pain; AND
- Imaging of the sacroiliac joint indicates evidence of injury and/or degeneration; AND
- There is at least a 75% reduction in pain for the expected duration of the anesthetic used following an image-guided, contrast-enhanced intra-articular sacroiliac joint injection on two separate occasions; AND
- A trial of a therapeutic sacroiliac joint injection (i.e., corticosteroid injection) has been performed on at least once.
The draft stated that minimally invasive fusion/stabilization of the sacroiliac joint will be considered not medically necessary and investigational for all other indications.
ISASS submitted comments to support the draft policy and ask for a narrower application to avoid use of clinically appropriate devices.