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Sacroiliac Joint Injections and Procedures: A New LCD Effective 3/19/2023

February 8, 2023

CGS (L39383), Palmetto (L39402), WPS (L39475), NGS (39455), and Noridian (L39462 and L39464) jurisdictions, have issued SI joint injection policies:

Novitas and First Coast Services have not issued their policies nor have they participated in multijurisdictional committee and have not issued a policy. 

You can use this algorithmic approach whenever you see your patients by utilizing these checklists for each patient prior to performing epidural steroid injections and facet joint interventions. 

Sacroiliac Joint Injections and Procedures- Algorithmic Approach and Checklists

●  Sacroiliac joint injections CPT 27096 and sacroiliac joint nerve blocks are listed as covered procedures.
●  Radiofrequency neurotomy is no longer a covered procedure and is considered as investigational.

Criteria for Diagnostic Blocks (5 Components)
●  Moderate to severe axial low back pain over anatomic location of the SI joints below L5
●  3 months duration of pain
●  At least 3 positive findings with provocative maneuvers:

• SI Compression
• Gaenslen
• SI Distraction
• Thigh Thrust
• Yeoman Tests
• Posterior Shear

●  Inadequate response to conservative methods at least for 4 weeks (chiropractic, physical therapy, structured exercise program, NSAIDs, and other drugs) with duration and effects
●  No untreated radiculopathy (current imaging)

Diagnostic Sacroiliac Joint Injections

●  Patient’s meeting the covered indications are provided with 2 diagnostic blocks with minimum of 75% relief of index pain, sustained and constant pain relief for the duration of local anesthetic as measured by the same pain scale at baseline.
●  The measurements must be documented pre-injection and post-injection on the day of the injection, and the days following the injection to substantiate and corroborate the pain scores consistent with the pain relief for the duration of the local anesthetic and/or steroid used.
●  Limitations include, no more than 2 diagnostic joint sessions.

Therapeutic Sacroiliac Joint Injections

●  For patients with positive response to diagnostic intraarticular injections, sacroiliac joint injections with concordant 75% relief, therapeutic sacroiliac joint injections are considered medically reasonable and necessary with at least 50% pain relief or at least 50% consistent improvement in the ability to perform previously painful movements and activities of daily living at least for 3 months.
Sacroiliac joint injections must be performed under CT or fluoroscopy.
●  No more than 4 therapeutic sacroiliac joint injections sessions, unilateral or bilateral, will be reimbursed per rolling 12 months.
●  Left and right in separate sessions will be considered as 2 sessions for the limitation of 4 therapeutic sessions per rolling 12 months.
●  Sacroiliac joint radiofrequency ablation is not considered reasonable and necessary.

It would be appropriate to utilize a checklist to assure that these procedures are performed properly: Checklist

Hopefully this detailed information and checklists will assist in your practice. If you have any questions, please feel free to contact us.nject


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