Purpose: The practice alert informs members of the recent 2023 Sacroiliac Joint Injections and Procedures Local Coverage Document (LCD). The alert links important related documents and tips to help integrate sacroiliac joint injection LCD coverage decisions into practitioners’ practices. Members should be aware of their own local and state policies, which also impact the use of these important diagnostic and therapeutic injections for the treatment of sacroiliac joint related pain. This bulletin also includes a link to the March 7, 2023, letter to the National Government and Medical Policy Unit of CMS AAPM signed in cooperation with eleven other national pain management and interventional pain societies, the Multisociety Pain Workgroup (MPW) voicing our shared concern and disappointment for the LCD’s decision to eliminate access to radiofrequency ablation procedures for sacroiliac joint pain for Medicare beneficiaries. AAPM strongly recommends that members read the LCD document, including the literature review for sacroiliac joint pain procedures. Currently, almost all Medical Administrative Contractors (MACs) have adopted an LCD on sacroiliac joint injections. Clinicians are encouraged to contact their MAC to determine whether an LCD has been adopted for their state.
BULLETIN OVERVIEW
I. General overview of Local Coverage Document (LCD)
II. Overview of LCD-Sacroiliac Joint Injections and Procedures (L39383)
III. March 7, 2023, Multispecialty Pain Workgroup (MPW) letter to CMS
IV. Take home points for AAPM Members
INFORMATIONAL BULLETIN
- Overview of LCD and Sacroiliac Joint Injections and Procedures (L39383) links and documents
- LINK: LCD – Sacroiliac Joint Injections and Procedures (L39383) (cms.gov)
- What is an LCD?
- A Local Coverage Determination (LCD) is a decision made by a Medicare Administrative Contractor (MAC) about whether a specific service or item is deemed to be reasonable and necessary, “and therefore covered by Medicare within the specific jurisdiction” that the MAC oversees.
- Who does the LCD apply to?
- All patient care administered through Medicare Administrative Contractors who have adopted the LCD. Find the MAC administering your state here: (MACs by State June 2021 (cms.gov)
- Currently, almost all MACs have adopted the LCD, although the LCD identifier (ID) may vary by MAC. Clinicians are encouraged to contact their MAC to determine whether the LCD has been adopted for their state. A proposed LCD list can be found at: https://www.cms.gov/medicare-coverage- database/reports/local-coverage-proposed-lcds-alphabetical-report.aspx?proposedStatus=all. Search under the tab for the letter “S” to find links to all LCDs for sacroiliac joint injections, including MAC and effective dates]
- Overview of LCD-Sacroiliac Joint Injections and Procedures (L39383)
- Covered Indications
- SACROILIAC joint injections (SIJI) will be considered medically reasonable and necessary when ALL the following requirements are met: Moderate to severe low back pain primarily experienced over the anatomical location of the SI joints between the upper level of the iliac crests and the gluteal fold, AND Low back pain duration of at least three (3) months, AND Low back pain below L5 without radiculopathy, AND Clinical findings and/or imaging studies do not suggest any other diagnosed or obvious cause of the lumbosacral pain (such as central spinal stenosis with neurogenic claudication/myelopathy, foraminal stenosis or disc herniation with concordant radicular pain/radiculopathy, infection, tumor, fracture, pseudoarthrosis, or pain related to spinal instrumentation), AND At least three positive findings with provocative maneuvers: FABER, Gaenslen, Thigh Thrust or Posterior Shear, SI Compression, SI Distraction and Yeoman Tests, AND Low back pain persists despite a minimum of four weeks of conservative therapies.
- Covered Indications
- Diagnostic Sacroiliac Joint Injections
- Diagnostic SIJI is used to determine if the etiology of pain is from the SACROILIAC joint complex.
- Diagnostic SIJI are considered reasonable and necessary for patients who meet ALL the following criteria:
- The patient must meet the above criteria for Covered Indications for SIJI, AND The SI joint injections must be performed under CT or fluoroscopy image guidance with contrast, except ultrasound guidance may be considered reasonable and necessary when there is a documented contrast allergy or pregnancy, since the accuracy with ultrasound guidance is inferior to fluoroscopic guidance, AND SI joint injection are not performed with other musculoskeletal injections in the lumbosacral spine, AND The documentation should show direct causal benefit from the SI joint injection and not from other musculoskeletal injections or treatments, AND The diagnostic SIJI provided a minimum of 75% relief of primary (index) pain with the diagnostic SIJI (a positive diagnostic response is defined as ≥75% sustained and constant pain relief for the duration of the local anesthetic and ≥75% sustained and constant pain relief for the duration of the anti-inflammatory steroid) was measured by the SAME pain scale at baseline. The measurements of pain must be taken pre-injection on the day of the SIJ injection, post- intervention 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: No more than two (2) diagnostic joint sessions, unilateral or bilateral. To clarify, two unilateral sessions, if performed on one side at one session and on the opposite side at a different session, would meet the limitation of two (2) diagnostic sessions.
- Therapeutic Sacroiliac Joint Injections
- Therapeutic SIJI will be considered medically reasonable and necessary for patients who meet ALL the following criteria:
- The patient must meet the above criteria of Covered Indications for SIJI, AND The diagnostic SIJI provided a minimum of 75% relief of primary (index) pain with the diagnostic SIJI (a positive diagnostic response is defined as ≥75% sustained and constant pain relief for the duration of the local anesthetic and ≥75% sustained and constant pain relief for the duration of the anti-inflammatory steroid) was measured by the SAME pain scale at baseline. The measurements of pain were taken pre- injection on the day of the diagnostic SIJ injection, post-intervention on the day of the diagnostic injection, and the days following the diagnostic SIJ injection to substantiate and corroborate consistent pain relief for the duration of the local anesthetic and/or steroid used, AND Subsequent therapeutic SIJI are considered medically reasonable and necessary when the subsequent SIJI are provided at the same anatomic site as therapeutic SIJI, AND the therapeutic SIJI produced at least consistent 50% pain relief or at least 50% consistent improvement in the ability to perform previously painful movements and activities of daily living (ADLs) for at least three (3) months from the proximate therapeutic SIJI procedure and compared to baseline measurements for ADLS and painful movements or pain relief using the same pain scale AND The SI joint injections must be performed under CT or fluoroscopy image guidance with contrast, except ultrasound guidance may be considered reasonable and necessary when there is a documented contrast allergy or pregnancy, since the accuracy with ultrasound guidance is inferior to fluoroscopic guidance.
- Limitations: No more than four (4) therapeutic SIJI sessions, unilateral or bilateral, will be reimbursed per rolling 12 months. To clarify, a therapeutic SIJI session, if performed on one side first and then on the opposite side at a different session, would qualify as two (2) sessions for the limitation of four (4) therapeutic SIJ sessions per rolling 12 months.
- Therapeutic SIJI will be considered medically reasonable and necessary for patients who meet ALL the following criteria:
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- Sacroiliac Joint Denervation (Radiofrequency Ablation)
- Sacroiliac Joint Radiofrequency Ablation is not considered reasonable and necessary and is NO LONGER COVERED.
- Sacroiliac Joint Denervation (Radiofrequency Ablation)
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- Requirements
- See LCD link for full details.
- Requirements
-
- Limitations
- See LCD link for full details.
- Limitations
-
- Provider Qualifications
- See LCD link for full details.
- Provider Qualifications
- Multisociety Pain Workgroup (MPW) March 7, 2023, Letter to CMS
- Take Home Points for AAPM Members
- Read the document. All clinicians who diagnose and treat sacroiliac disorders are HIGHLY encouraged to personally read the LCD at the following link: LCD – Sacroiliac Joint Injections and Procedures (L39383) (cms.gov). The LCD document is expansive and provides and additional degree of clarification regarding the elements summarized above.
- Practice Implications
- Covered Indications: Very specific documentation is required to demonstrate medical
necessity. Clinicians may want to consider a structured document template to make sure they have documented all of the required elements including:- pain severity (moderate to severe)
- pain duration (3 or more months)
- Pain location over the SIJ (not above L5 or below the gluteal fold)
- failure of conservative treatment (minimum of 4 weeks)
- Three (3) positive findings with provocative maneuvers (FABER, Gaenslen, Thigh Thrust or Posterior Shear, SI Compression, SI Distraction and Yeoman Tests)
- Procedure Types: The LCD defines two types of injections Diagnostic & Therapeutic.
Interestingly, diagnostic injections may be performed with local anesthetic alone (which makes the most sense), or with local anesthetic and corticosteroid. A diagnostic injection is considered positive when pain relief of 75% is achieved for the duration of the injected medication. The LCD does not specifically state a required duration of effect. Logically for local anesthetic only injections, this will be in the realm of 4-6 hours depending on the agent used. The LCD however does not provide any guidance on the minimal or expected duration of effect when steroids are included in the injection. Seemingly, this is up to the provider to define. - Diagnostic procedures: Only 2 diagnostic procedures are permitted, and the patient must achieve 75% pain relief for the duration of the medication used in order to proceed with subsequent therapeutic injections. Thus, the role of a diagnostic injection per this LCD appears to be to identify patients for subsequent therapeutic injection. There is no discourse on using diagnostic injections to select patients for possible surgical intervention (SIJ fusion) but this is also a logical deduction. Seemingly there is now no role for lateral branch nerve blocks for the diagnosis of SIJ pain, since lateral branch RFA is no longer a covered indication.
- Therapeutic Injections: There are very strict documentation requirements necessary in order to proceed with subsequent therapeutic injections. Specifically, patients must experience at least 50% constant pain relief as measured with the same validated pain scale on the day of the procedure and at a minimum of 3 months post procedure (with the SAME pain scale) demonstrating 50% relief. The LCD excerpt below highlights the importance CMS has placed on this stringent documentation:
- “When documenting the percentage of pain relief from the primary (index) pain compared to the post-injection pain levels, it is insufficient to report only a percentage of pain relief and/or a nonspecific statement of the duration of pain relief. The documentation should include a specific assessment of the duration of relief being consistent or inconsistent with the agent used for the injection and the specific dates the measurements were obtained using the SAME pain scale used at baseline.”
- Covered Indications: Very specific documentation is required to demonstrate medical