Sacroiliac Joint Dysfunction denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for radiofrequency ablation with Coolief technology and monitored anesthesia care (MAC). Sacroiliac joint dysfunction (SIJ) is a very common cause of refractory lower back pain commonly felt in the gluteal region but may also affect the lower extremities and/or the lumbar region. In a study, the authors evaluated radiofrequency ablation (RFA) of the sacroiliac joint (SI) joint and found that all patients who underwent RFA reported excellent pain relief and ceased taking analgesic medications.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral sacroiliac (SI) joint fusion surgery. Polly and colleagues concluded that minimally invasive SI joint fusion using triangular titanium implants was more effective than nonsurgical management at one year in relieving pain, improving function, and improving quality of life in patients with SI joint dysfunction caused by degenerative sacroiliitis or SI joint disruptions. The International Society for Advancement of Spine Surgery (ISASS) policy statement for minimally invasive SI joint fusion provide specific indications for surgery (Lorio and Rashbaum).

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for posterior sacroiliac joint fusion procedure. Researchers explain, “The sacroiliac joint may be a primary source of pain in patients complaining of low back and/or buttock pain. Nonsurgical treatment of sacroiliac joint pain typically includes structured core and pelvic muscle flexibility and strengthening; pharmaceutical management through oral and injectable medication; and ablation procedures. For patients who do not improve with comprehensive, nonoperative treatment, surgical fusion of the sacroiliac joint is an option with overall good reported outcomes and high patient satisfaction. Minimally invasive surgery (MIS) approaches have been shown to have lower morbidity and earlier recovery than traditional open approaches.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for sacroiliac joint (SIJ) fusion using the Catamaran SIJ Fusion System. The Catamaran SIJ Fusion System is safe and effective in relieving pain and reducing disability in patients with chronic SIJ pain. According to a study, “Sacroiliac (SI) joint dysfunction is a common cause of low back pain and accurate diagnosis can be challenging. A complete history and physical examination are critical in differentiating other diagnoses that may have similar signs and symptoms. Positive responses to at least three physical provocation tests suggest SI joint dysfunction.” The authors noted that patients whose symptoms do not improve with conservative management may benefit from interventional treatment options, including SIJ fusion.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving sacroiliac joint dysfunction, then check the rights and deadlines that apply to your plan.