Sacroiliac Joint Pain 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 has requested authorization and coverage for radiofrequency ablation. In a study evaluating radiofrequency ablation of the sacroiliac joint in 40 patients, researchers reported that all 40 patients who underwent radiofrequency ablations reported excellent pain relief at three and six months. The authors went on to report that at the 24-month mark, 17 patients reported good pain relief, and 19 patients reported excellent pain relief. The authors further noted that all patients who reported excellent pain relief discontinued their previous pain medication completely.

Findings: The physician reviewer found that the patient has requested reimbursement for the sacroiliac joint injection.. A review on sacroiliac (SI) joint pain diagnosis and treatment stated, `In particular, various studies have reported that three or more than three provocation tests might provide a more sensitive and specific identification of the stress from the SI joint.` The authors concluded, `The diagnosis and management of patients with SI joint pain remains challenging. There are no specific historic features, provocation tests or radiological findings to provide a definite diagnosis of SI join pain.

Where the denial was upheld

Findings: The physician reviewer found that an enrollee has requested authorization and coverage for the Intercept procedure. In this case, the patient is being treated for vertebrogenic low back pain. In notes, the patient reported sacroiliac joint pain, greater on the left than on the right, that worsened with prolonged sitting. He reported vertebrogenic pain with bending forward. On examination, there was pain with range of motion in all planes, most with flexion, and left-sided sacroiliac joint tenderness. Flexion Abduction External Rotation (FABER), iliac compression, and Gaenslen’s tests were positive on the left. The U.S.

Nature of Statutory Criteria/Case Summary: An enrollee has requested sacroiliac joint fusion for treatment of the enrollee’s sacroiliac (SI) joint pain. Findings: Two physician reviewers found that evidence based medical guidelines support SI joint fusion (either open or percutaneous) on an individual basis as a last line of therapy for ongoing symptoms, corroborating physical exam findings and imaging, and after failure of non-operative treatment for SI joint infection, tumor, disabling pain due to sacroiliitis due to spondyloarthropathy, SI pain due to severe traumatic injury, and in conjunction with multisegmental spinal constructs. Suggested physical exam indicators of pain related to SI joint pathology include documentation of at least three positive exam findings to suggest the diagnosis.

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 pain, then check the rights and deadlines that apply to your plan.