Sacroiliac Joint Injection denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for cervical/thoracic interlaminar epidural injection and/or sacroiliac joint injection. With regard to the request for cervical epidural steroid injection, there is medical evidence supporting this treatment modality in specific patients. Medical literature noted that, “repeat steroid injections are a justifiable form of treatment in symptomatic patients with lumbar or cervical disc herniation whose symptoms are not satisfactorily relieved after the first injection.” This patient’s records document chronic neck pain with a diagnosis of cervical radiculopathy and severe degeneration with a C5-6 and C6-7 disc herniation with stenosis. The provider notes that the patient is experiencing neck pain and bilateral upper extremity paresthesias.

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

Nature of Statutory Criteria/Case Summary: An enrollee was diagnosed with right sacroiliac (SI) joint pain. The patient was injured in a motor vehicle accident. The patient’s provider recommended a right sacroiliac joint injection, as she had symptoms and findings consistent with SI joint pain. At that time, her pain was rated as 2 to 3 out of 10. She underwent a right SI joint injection under fluoroscopy. She returned to the neurosurgeon and reported that her pain was a 3 to 7 out of 10 at that time, and she was unsure of whether the injection helped, as she had been quite inactive afterwards, and the pain was low following the injection. The provider recommended a repeat SI joint injection under computed tomography (CT) guidance. The patient returned to her provider and she reported her pain as having improved to a 1 out of 10.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for sacroiliac (SI) joint injection. Findings: In this case, the provider’s notes state that the patient has low back pain radiating into the right lower extremity consistent with the nerve distribution of L4, L5, and S1. A magnetic resonance imaging (MRI) confirms narrowing of the neural foramina at L4-5, and CT demonstrated disc protrusions at L 4-5 and L5-S1, which are consistent with the patient’s symptoms. The provider’s note state the straight leg test was positive at 45 degrees, which is suggestive of a lumbar radicular pain pattern and not an SI joint pain pattern.

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