Medical policy: Diagnosis and Treatment of Sacroiliac Joint Pain

Policy number: MP 5.048

Effective date: 4/1/2026

Policy

Sacroiliac joint arthrography

Arthrography of the sacroiliac joint (SIJ) is considered investigational. There is insufficient evidence to support a conclusion concerning the general health outcomes or benefits associated with this procedure.

Sacroiliac joint injection

Injection of anesthetic for diagnosing SIJ pain may be considered medically necessary when the following criteria have been met:

• Pain has failed to respond to 3 months of conservative management, which may consist of therapies such as nonsteroidal anti-inflammatory medications, acetaminophen, manipulation, physical therapy, and a home exercise program; and
• Dual (controlled) diagnostic blocks with 2 anesthetic agents with differing duration of action are used; and
• The injections are performed under imaging guidance.

Injection of corticosteroid may be considered medically necessary for the treatment of SIJ pain when the following criteria have been met:

• Pain has failed to respond to 3 months of conservative management, which may consist of therapies such as nonsteroidal anti-inflammatory medications, acetaminophen, manipulation, physical therapy, and a home exercise program; and
• The injection is performed under imaging guidance; and
• No more than three injections are given per twelve-month period.

Sacroiliac injections are considered investigational for indications other than those listed above. There is insufficient evidence to support a conclusion concerning the general health outcomes or benefits associated with this procedure.

Radiofrequency ablation

Radiofrequency ablation (RFA) of the sacroiliac joint is considered investigational. There is insufficient evidence to support a conclusion concerning the general health outcomes or benefits associated with this procedure.

Policy guidelines

This policy does not address the treatment of sacroiliac joint pain due to infection, trauma, or neoplasm.

Conservative nonsurgical therapy for the duration specified should include the following:

• Use of prescription strength analgesics for several weeks at a dose sufficient to induce a therapeutic response
  • Analgesics should include anti-inflammatory medications with or without adjunctive medications such as nerve membrane stabilizers or muscle relaxants AND
• Participation in at least 6 weeks of physical therapy (including active exercise) or documentation of why the patient could not tolerate physical therapy, AND
• Evaluation and appropriate management of associated cognitive, behavioral, or addiction issues
• Documentation of patient compliance with the preceding criteria

A successful trial of controlled diagnostic lateral branch blocks consists of two separate positive blocks on different days with local anesthetic only (no steroids or other drugs), or a placebo-controlled series of blocks, under fluoroscopic guidance, that has resulted in a reduction in pain for the duration of the local anesthetic used (e.g., 3 hours long with bupivacaine than with lidocaine).

There is no consensus on whether a minimum of 50% or 75% reduction in pain would be required to be considered a successful diagnostic block, although evidence that supported a criterion standard of 75% to 100% reduction in pain with dual blocks.

No therapeutic intra-articular injections (i.e., steroids, saline, other substances) should be administered for a period of at least 4 weeks before the diagnostic block. The diagnostic blocks should not be conducted under intravenous sedation unless specifically indicated (e.g., the patient is unable to cooperate with the procedure).

Cross-references

• MP 5.049 Facet Joint Denervation
• MP 2.061 Prolotherapy

Product variations

This policy is only applicable to certain programs and products administered by Capital Blue Cross and subject to benefit variations. Please see additional information below.

FEP PPO - Refer to FEP Medical Policy Manual.

Description/background

Sacroiliac joint pain

Similar to other structures in the spine, it is assumed that the sacroiliac joint (SIJ) may be a source of low back pain. In fact, before 1928, the SIJ was thought to be the most common cause of sciatica. In 1928, the role of the intervertebral disc was elucidated, and from that point forward, the SIJ received less research attention.

Diagnosis

Research into SIJ pain has been plagued by lack of a criterion standard to measure its prevalence and against which various clinical examinations can be validated. For example, SIJ pain typically presents without any consistent, demonstrable radiographic or laboratory features and most commonly exists in the setting of morphologically normal joints.

Clinical tests for SIJ pain may include various movement tests, palpation to detect tenderness, and pain descriptions by the patient. Further confounding the study of the SIJ is that multiple structures (e.g., posterior facet joints, lumbar discs) may refer pain to the area surrounding the SIJ.

Because of inconsistent information obtained from history and physical examination, some have proposed the use of image-guided anesthetic injection into the SIJ for the diagnosis of SIJ pain.

Treatments being investigated for SIJ pain include prolotherapy (see Medical Policy 2.061), corticosteroid injection, radiofrequency ablation, stabilization, and arthrodesis.

Some procedures have been referred to as SIJ fusion but are more appropriately called fixation due to little to no bridging bone on radiographs. Devices for SIJ fixation/fusion include triangular implant (iFuse Implant System) and cylindrical threaded devices (Rialto, SIJoint, Silex, SambaScrew, SI-LOK).

Some devices also have a slot in the middle where autologous or allogeneic bone can be inserted. This added bone is intended to promote fusion of the SIJ.

Regulatory status

A number of radiofrequency generators and probes have been cleared for marketing by the U.S. Food and Drug Administration (FDA) through the 510(k) process. In 2005, the Stryker® (Halard) formerly Kimberly-Clark, a water- cooled single-use probe, was cleared by the FDA, listing the Baylis Pain Management Probe as a predicate device.

The intended use is in conjunction with a radiofrequency generator to create radiofrequency lesions in nervous tissue. FDA product codes: GXD, GXI.

Rationale

Summary of evidence

For individuals who have suspected SIJ pain who receive a diagnostic sacroiliac block, the evidence includes systematic reviews. Relevant outcomes are test validity, symptoms, functional outcomes, quality of life, medication use, and treatment-related morbidity.

Current evidence is conflicting on the diagnostic utility of SIJ blocks. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have SIJ pain who receive therapeutic corticosteroid injections, the evidence includes systematic reviews, randomized controlled trials (RCTs), and case series.

Relevant outcomes are symptoms, functional outcomes, quality of life, medication use, and treatment-related morbidity. In general, the literature on injection therapy of joints in the back is of poor quality.

Results from one RCT showed superiority over a sham control group, but two RCTs showed that therapeutic SIJ steroid injections were not as effective as other active treatments. Larger trials with rigorous designs and sufficient follow-up, preferably using sham injections, are needed to determine that the technology improves the net health outcome. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have SIJ pain who receive radiofrequency ablation (RFA), the evidence includes RCTs using different techniques, functional outcomes, quality of life, medication use, and treatment-related morbidity.

Meta-analysis of available sham controlled RCTs suggests that there may be a small effect of RFA on SIJ pain at short-term (1–6 months) follow-up. However, the RCTs of RFA have methodological limitations, and there is limited data on the duration of treatment effect.

For RFA with a cooled probe, three RCTs reported short-term benefits, but these are insufficient to determine the overall effect on health outcomes. An RCT on palisade RFA of the SIJ did not include a sham control.

Another sham-controlled RCT showed no benefit from RFA. Further high-quality controlled trials are needed to compare this procedure in defined populations with sham control and alternative treatments. The evidence is insufficient to determine the effects of the technology on health outcomes.

Definitions

Arthrography is a diagnostic study that involves the injection of contrast media into a joint.

Disclaimer

Capital Blue Cross’ medical policies are used to determine coverage for specific medical technologies, procedures, equipment, and services. These medical policies do not constitute medical advice and are subject to change as permitted by law or applicable clinical evidence from independent treatment guidelines. Treating providers are solely responsible for medical advice and treatment of members. These policies are not a guarantee of coverage or payment. Payment of claims is subject to a determination regarding the member’s benefit program and eligibility on the date of service, and a determination that the services are medically necessary and appropriate. Final processing of a claim is based upon the terms of contract that applies to the member’s benefit program, including benefit limitations and exclusions. If a provider or a member has a question concerning this medical policy, please contact Capital Blue Cross’ Provider Services or Member Services.

Coding information

Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement.

Investigational when used to bill for sacroiliac joint arthrography; therefore, not covered

Investigational when billed for radiofrequency ablation of the sacroiliac joint; therefore, not covered

Covered when medically necessary

*Note: For codes 27278, 27279, 27280, and C1737 related to arthrodesis and spinal devices, refer to TurningPoint Healthcare policies.

References

1. Himstead AS, Brown NJ, Shahrestani S, et al. Trends in Diagnosis and Treatment of Sacroiliac Joint Pathology Over the Past 10 Years: Review of Scientific Evidence for New Devices for Sacroiliac Joint Fusion. Cureus. Jun 2021; 13(6): e15415. PMID 34249562
2. Dreyfuss P, Michaelsen M, Pauza K, et al. The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine (Phila Pa 1976). Nov 15 1996; 21(22): 2594-602. PMID 8961447
3. Simopoulos TT, Manchikanti L, Gupta S, et al. Systematic Review of the Diagnostic Accuracy and Therapeutic Effectiveness of Sacroiliac Joint Interventions. Pain Physician. 2015; 18(5): E713-56. PMID 26431129
4. Manchikanti L, Abdi S, Atluri S, et al. An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain Physician. Apr 2013; 16(2 Suppl): S49-283. PMID 23615883
5. Manchikanti L, Datta S, Derby R, et al. A critical review of the American Pain Society clinical practice guidelines for interventional techniques: part 1. Diagnostic interventions. Pain Physician. 2010; 13(3): E141-74. PMID 20495596
6. Manchikanti L, Datta S, Gupta S, et al. A critical review of the American Pain Society clinical practice guidelines for interventional techniques: part 2. Therapeutic interventions. Pain Physician. 2010; 13(4): E215-64. PMID 20648212
7. Rupert MP, Lee M, Manchikanti L, et al. Evaluation of sacroiliac joint interventions: a systematic appraisal of the literature. Pain Physician. 2009; 12(2): 399-418. PMID 19305487
8. Chou R, Atlas SJ, Stanos SP, et al. Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine (Phila Pa 1976). May 01 2009; 34(10): 1078-93. PMID 19363456
9. Chou R, Loeser JD, Owens DK, et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine (Phila Pa 1976). May 01 2009; 34(10): 1066-77. PMID 19363457
10. Hansen H, Manchikanti L, Simopoulos TT, et al. A systematic evaluation of the therapeutic effectiveness of sacroiliac joint interventions. Pain Physician. 2012; 15(3): E247-78. PMID 22622913
11. Patel A, Kumar D, Singh S, et al. Effect of Fluoroscopic-Guided Corticosteroid Injection in Patients With Sacroiliac Joint Dysfunction. Cureus. Mar 2023; 15(3): e36406. PMID 37090293
12. Wissler H, Woudenberg NP, de Bont J, et al. Treatment of the sacroiliac joint in patients with leg pain: a randomized-controlled trial. Eur Spine J. Oct 2013; 22(10): 2310-7. PMID 23720124
13. Kim WM, Lee HG, Jeong CW, et al. A randomized controlled trial of intra-articular prolotherapy versus steroid injection for sacroiliac joint pain. J Altern Complement Med. Dec 2010; 16(12): 1285-90. PMID 21138388
14. Kennedy DJ, Engel A, Kreiner DS, et al. Fluoroscopically Guided Diagnostic and Therapeutic Intra-Articular Sacroiliac Joint Injections: A Systematic Review. Pain Med. Aug 2015; 16(8): 1500-18. PMID 26178855
15. Ah Aziz SN, Zakaria Mohamad Z, Karpulah RK, et al. Efficacy of Sacroiliac Joint Injection With Anesthetic and Corticosteroid: A Prospective Observational Study. Cureus. Apr 2022; 14(4): e24039. PMID 35547453
16. Al Khayyat FS, Foliga G, Barbagli S, et al. Ultrasound guided corticosteroids sacroiliac joint injections (SIJIs) in the management of active sacroiliitis: a real-life prospective experience. Ultrasound J. Jan 2023; 26(2): 479-486. PMID 36229757
17. Chandrupatla RS, Shahidi B, Bruno K, et al. A Retrospective Study on Patient-Specific Predictors for Non-Response to Sacroiliac Joint Injections. Int J Environ Res Public Health. Nov 23 2022; 19(23). PMID 36479595
18. Janapala RN, Knezevic NN, et al. Systematic Review and Meta-Analysis of the Effectiveness of Radiofrequency Ablation of the Sacroiliac Joint. Curr Pain Headache Rep. May 2024; 28(5): 335-372. PMID 38472618
19. Chou R, Fu R, Dana T, Papas M, Hart E, Mauer KM. Interventional Treatments for Acute and Chronic Pain: Systematic Review. Comparative Effectiveness Review No. 247. Rockville, MD: Agency for Healthcare Research and Quality; September 2021-EHC030. Rockville, MD: Agency for Healthcare Research and Quality; September 2021. PMID 34524764
20. Chappell ME, Lakshman R, Trotter P, et al. Radiofrequency denervation for chronic back pain: a systematic review and meta-analysis. BMJ Open. Jul 21 2020; 10(7): e035540. PMID 32699129
21. Juch JNS, Maas ET, Ostelo RWJG, et al. Effect of Radiofrequency Denervation on Pain Intensity Among Patients With Chronic Low Back Pain: The Mint Randomized Clinical Trial. JAMA. Jul 04 2017; 318(1): 68-81. PMID 28690736
22. Chen CH, Wang PW, Wu LC, et al. Radiofrequency neurotomy in chronic lumbar and sacroiliac joint pain: a meta-analysis. Medicine (Baltimore). Jun 2019; 98(26): e16230. PMID 31261580
23. Cohen SP, Kapoor L, Khan K, et al. Cooled radiofrequency ablation versus standard medial branch radiofrequency ablation for chronic sacroiliac joint pain: a multicenter, randomized comparative effectiveness study. Reg Anesth Pain Med. Mar 04 2024; 49(3): 184-191. PMID 37407279
24. Mehta V, Poply K, Husband M, et al. The Effects of Radiofrequency Neurotomy Using a Strip-Lesioning Device on Patients with Sacroiliac Joint Pain: Results from a Single-Center, Randomized, Sham-Controlled Trial. Pain Physician. Nov 2018; 21(6): 607-618. PMID 30508988
25. van Tilburg CW, Schuurmans FA, Stronks DL, et al. Randomized Sham-controlled Double-Blind Multicenter Clinical Trial to Ascertain the Effect of Percutaneous Radiofrequency Treatment for Sacroiliac Joint Pain: Three-month Results. Clin J Pain. Nov 2016; 32(11): 921-926. PMID 26889616
26. Zheng Y, Gu M, Shi D, et al. Homograft palisade sacroiliac joint radiofrequency neurotomy versus celecoxib for ankylosing spondylitis: a open-label, randomized, controlled trial. Rheumatol Int. Sep 2014; 34(9): 1195-202. PMID 24518967
27. Patel N, Gross A, Brown L, et al. A randomized, placebo-controlled study to assess the efficacy of lateral branch neurotomy for chronic sacroiliac joint pain. Pain Med. Mar 2012; 13(3): 383-98. PMID 22299761
28. Patel N, Tew V, Month Folluw-Up of a Randomized Trial Assessing Cooled Radiofrequency Denervation as a Treatment for Sacroiliac Region Pain. Pain Pract. Feb 2016; 16(2): 154-67. PMID 25565322
29. Ghadder A, Alsharef H, Alsharef HK, et al. Minimally invasive sacroiliac joint fusion using triangular titanium implants versus nonsurgical management for sacroiliac joint dysfunction: a systematic review and meta-analysis. Can J Surg. 2024; 67(1): E16-E26. PMID 38278549
30. Whang PG, Cher D, Polly D, et al. Sacroiliac Joint Fusion Using Triangular Titanium Implants vs. Non-Surgical Management: Six-Month Outcomes from a Prospective Randomized Controlled Trial. Int J Spine Surg. 2015; 9: 6. PMID 25785242
31. Polly DW, Cher D, Wine KD, et al. Randomized Controlled Trial of Minimally Invasive Sacroiliac Joint Fusion Using Triangular Titanium Implants vs Nonsurgical Management for Sacroiliac Joint Dysfunction: 12-Month Outcomes. Neurosurgery. Nov 2015; 77(5): 674-94; discussion 690-1. PMID 26291338
32. Polly DW, Swroford J, Whang PG, et al. Two-Year Outcomes from a Randomized Controlled Trial of Minimally Invasive Sacroiliac Joint Fusion vs. Non-Surgical Management for Sacroiliac Joint Dysfunction. Int J Spine Surg. 2016; 10: 28. PMID 27652199
33. Darr E, Meyer SC, Whang PG, et al. Long-term prospective outcomes after minimally invasive trans-iliac sacroiliac joint fusion using triangular titanium implants. Med Devices (Auckl). 2018; 11: 113-121. PMID 29674852
34. Sturesson B, Kool S, Pflugmacher R, et al. Six-month outcomes from a randomized controlled trial of minimally invasive SI joint fusion with triangular titanium implants versus conservative management. Eur Spine J. Mar 2017; 26(3): 708-719. PMID 27179664
35. Dengler J, Sturesson B, Kool S, et al. Referred leg pain originating from the sacroiliac joint: 6-month outcomes from the prospective randomized controlled iMIA trial. Acta Neurochir (Wien). Nov 2016; 158(11): 2219-2224. PMID 27629371
36. Dengler JD, Kools D, Pflugmacher R, et al. 1-Year Results of a Randomized Controlled Trial of Conservative Management vs. Minimally Invasive Surgical Treatment for Sacroiliac Joint Pain. Pain Physician. Sep 2017; 20(6): 537-550. PMID 28934785
37. Dengler J, Kools D, Pflugmacher R, et al. Randomized Trial of Sacroiliac Joint Arthrodesis Compared with Conservative Management for Chronic Low Back Pain Attributed to the Sacroiliac Joint. J Bone Joint Surg Am. Mar 06 2019; 101(5): 400-411. PMID 30845034
38. Randers EM, Gerdhem P, Stuge B, et al. The effect of minimally invasive sacroiliac joint fusion compared to sham operation: a double-blind randomized placebo-controlled trial. EClinicalMedicine. Feb 2024; 68: 102443. PMID 38328752
39. Duhon BS, Cher DJ, Wine KD, et al. Triangular Titanium Implants for Minimally Invasive Sacroiliac Joint Fusion: A Prospective Study. Global Spine J. May 2016; 6(3): 257-69. PMID 27099817
40. Duhon BS, Bitan F, Lockstadt H, et al. Triangular Titanium Implants for Minimally Invasive Sacroiliac Joint Fusion: 2-Year Follow-Up from a Prospective Multicenter Trial. Int J Spine Surg. 2016; 10: 13. PMID 27162715
41. Whang PG, Darr E, Meyer SC, et al. Long-Term Prospective Clinical and Radiographic Outcomes After Minimally Invasive Lateral Transiliac Sacroiliac Joint Fusion Using Triangular Titanium Implants. Med Devices (Auckl). 2019; 12: 411-422. PMID 31576181
42. Patel V, Kovalsky D, Meyer SC, et al. Prospective Trial of Sacroiliac Joint Fusion Using 3D-Printed Triangular Titanium Implants. Med Devices (Auckl). 2020; 13: 173-182. PMID 31576818
43. Vannacchio V, Herrera JM, Sáiz-Sapena N, et al. Minimally invasive Sacroiliac Joint Fusion, Radiofrequency Denervation, and Conservative Management for Sacroiliac Joint Pain: 6-Year Comparative Case Series. Neurosurgery. Jan 2018; 82(1): 48-55. PMID 28431026
44. Spain K, Holt T. Surgical Revision after Sacroiliac Joint Fixation or Fusion. Int J Spine Surg. 2017; 11(1): 5. PMID 28377863
45. Schoell K, Buser Z, Jakoi A, et al. Postoperative complications in patients undergoing minimally invasive sacroiliac joint fusion. Spine J. Nov 2016; 16(11): 1324-1332. PMID 27349627
46. Tran ZV, Ivashchenko A, Brooks L. Sacroiliac Joint Fusion Methodology - Minimally Invasive Compared to Screw-Type Surgeries: A Systematic Review and Meta-Analysis. Pain Physician. Jan 2019; 22(1): 29-40. PMID 30700606
47. Lorio M, Kube R, Araghi A. International Society for the Advancement of Spine Surgery Policy 2020 Update: Minimally Invasive Surgical Sacroiliac Joint Fusion (for Chronic Sacroiliac Joint Pain): Coverage Indications, Limitations, and Medical Necessity. Int J Spine Surg. Dec 2020; 14(Suppl 1): S80-S95. PMID 33560247
48. Rappoport LH, Kelsper K, Shirk T. Minimally Invasive sacroiliac joint fusion using a novel hydroxyapatite-coated screw: final 2-year clinical and radiographic results. J Spine Surg. Jun 2021; 7(2): 155-161. PMID 34296027
49. Fuchs V, Ruhl B. Distraction arthrodesis of the sacroiliac joint: 2-year results of a descriptive prospective multi-center cohort study in patients. Eur Spine J. Jan 2018; 27(1): 194-204. PMID 29058134
50. Caloney A, Azeem N, Buchanan P, et al. Safety, Efficacy, and Durability of Outcomes: Results from SECURE: A Single Arm, MultiCenter, Prospective, Clinical Study on a Minimally Invasive Posterior Sacroiliac Fusion Allograft Implant. J Pain Res. 2024; 17: 1209-1222. PMID 38524688
51. Kucharczyk D, Cole K, Boone C, et al. Clinical Outcomes Following Minimally Invasive Sacroiliac Joint Fusion With Dexticator: The EvoluSIon Clinical Study. Int J Spine Surg. Feb 2022; 16(1): 168-175. PMID 35217586
52. Splitt T, Pflugmacher R, Sollmann O, et al. Surgical Treatment of Patients with Sacroiliac Joint Syndrome: Comparative Study of Two Implants. Z Orthop Unfall. Nov 2023. PMID 37992733
53. Davies M, Dreischaff M, Yusubekov R, Catamran S. SI Joint Fusion System (R) MAINSAIL TM Study: a prospective, single-arm, multi-center, post-market study of six-month clinical outcomes and twelve-month radiographic findings. Expert Rev Med Devices. Sep 2024; 21(9): 851-858. PMID 39161110
54. North American Spine Society. Diagnosis and Treatment of Adults with Sacroiliac Joint Pain: A Protocol for a Systematic Review and Clinical Guidelines by the North American Spine Society. n.d. https://www.spine.org/Portals/0/assets/downloads/ResearchClinicalCare/Guidelines/SacroiliacJointPain-Protocol.pdf. Accessed October 5, 2024.
55. Benzon HT, Connis RT, De Leon-Casasola OA, et al. Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology. Apr 2010; 112(4): 810-33. PMID 20124882
56. Lee DW, Pritzlaff S, Jun MJ, et al. Latest Evidence-Based Application for Radiofrequency Neurotomy (LEARN): Best Practice Guidelines from the American Society of Pain and Neuroscience (ASPN). J Pain Res. 2021; 14: 2807-2831. PMID 34526815
57. Sayed D, Deer TR, Tieppo Francio V, et al. American Society of Pain and Neuroscience Best Practice (ASPN) Guideline for the Treatment of Sacroiliac Disorders. J Pain Res. 2024; 17: 1601-1638. PMID 38716038
58. National Institute for Health and Care Excellence. Minimally invasive sacroiliac joint fusion surgery for chronic sacroiliac joint pain [IPG578]. 2017; https://www.nice.org.uk/guidance/ipg578. Accessed October 4, 2024.
59. National Institute for Health and Care Excellence. iFuse for treating chronic sacroiliac joint pain [MTG39]. 2022; https://www.nice.org.uk/guidance/mtg39. Accessed October 4, 2024.