RetiredCareSourcePolicy Sacroiliac Joint Procedures-AR PASSE-MM-1507

Sacroiliac Joint Procedures (Injections and Radiofrequency Ablation)

Defines medical necessity criteria, exclusions/limitations, and billing interactions for diagnostic and therapeutic sacroiliac joint (SIJ) injections and radiofrequency ablation (RFA) for chronic low back pain for Arkansas PASSE members. Also addresses repeat procedures, implantable device considerations, and reimbursement bundling rules.

Policy Summary

PayerCareSource

PolicyMEDICAL POLICY STATEMENT Arkansas PASSE

Policy CodePolicy Sacroiliac Joint Procedures-AR PASSE-MM-1507

Change TypeReviewedreferences updatedarchived

Effective Date05/01/2025

Next Review Date

Key ActionSubmit prior authorization with documentation of duration and types of conservative therapies, SIJ provocation test results, diagnostic injection response (≥75% when required), injection timing, and device interrogation report if an implanted stimulator or pump is present.

SourceLink

POLICY UPDATE CHANGES

Policy reviewed 01/29/2025 with updated references and approved at Committee; effective date 05/01/2025 and archived 02/28/2026.

Initial policy issued 09/13/2023 as new policy.

2Maximum Diagnostic Injections Allowed

4Max Injections per Site per 12 Months

75%Required Pain Relief After Diagnostic Injection

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Coverage Summary

Status: RETIRED. Policy Title/Number: Sacroiliac Joint Procedures-AR PASSE-MM-1507. Effective date 05/01/2025; archived 02/28/2026. This policy defines medical necessity criteria, limitations, and billing rules for diagnostic and therapeutic sacroiliac joint (SIJ) injections and radiofrequency ablation (RFA) for chronic low back pain in Arkansas PASSE members. The policy applies to patients with somatic or nonradicular low back and/or lower extremity pain lasting at least 3 months and outlines required conservative therapy, diagnostic injection response thresholds, limits on injection frequency and counts, and criteria for initial and repeat RFA. The coverage stance is mixed: conservative, multimodal care is preferred; SIJ injections and RFA are permitted under specified criteria when conservative management fails.

I. Sacroiliac Joint Injections — Diagnostic

SIJ injections using local anesthetic and/or corticosteroid have demonstrable diagnostic value and can provide limited short-term relief. The policy notes that long-term efficacy of SIJ injections is not well established and that injections are intended mainly to aid diagnosis and short-term symptom control rather than guaranteed lasting benefit.

I. Sacroiliac Joint Injections — Therapeutic

II. Radiofrequency Ablation (RFA) — Initial RFA

Evidence for long-term benefit from RFA for SIJ-mediated low back pain is inconsistent with limited follow-up reported in the literature. Despite this, RFA may be reasonable for select patients when documented conservative management has failed and a diagnostic injection has produced the required response (eg, ≥75% pain reduction) prior to initial RFA.

II. Radiofrequency Ablation (RFA) — Repeat RFA

Provider Actions / Billing & Documentation

Prior Authorization

Prior authorization required with documentation

Prior authorization required with documentation. Submit documentation demonstrating duration and types of conservative therapies (active and inactive), results of SIJ provocation tests, diagnostic injection response (≥75% pain relief when required), timing between injections (at least 1 week between diagnostic injections), and a device interrogation report if the member has an implanted spinal cord stimulator or pain pump.

Documentation Required

Conservative therapy documentation

Conservative therapy documentation: include medical record evidence of at least 6 weeks of active conservative therapy within the past 6 months (or documentation of inability to complete active therapy for a clinical reason) and at least 6 weeks of inactive conservative therapy within the past 6 months to support diagnostic injections or RFA.

Coding and Billing Rules

Potentially conflicting/prohibited same-day codesCPT

64451	Injection, anesthetic agent; first sacroiliac joint, diagnostic or therapeutic (do not bill with 27096 on same date for same side)
27096	Injection procedure for sacroiliac joint (do not bill with 64451 on same date for same side)

Image guidance and contrastCPTNot Covered

No codes listed

Billing rules: CPT codes 64451 and 27096 may not be billed together on the same date for the same side; only one will be reimbursed. Image guidance and injection of contrast for SIJ injections are included in the procedure reimbursement and may not be billed separately. Injections applied to different regions or sides must be performed at least 1 week apart.

Background, Evidence & Definitions

Sacroiliac joint pain may account for approximately 10–25% of persistent low back pain. The policy emphasizes a preference for comprehensive, multimodal conservative management (active and inactive therapies) before interventional procedures. SIJ injections have diagnostic utility and provide limited short-term pain relief, but long-term effectiveness is not well established. RFA is described as a minimally invasive option with inconsistent long-term evidence; it may be offered when conservative therapy fails and diagnostic injections demonstrate a significant response.

Label	Value
Diagnostic injection efficacy	Short-term relief demonstrated; long-term efficacy not well established
RFA evidence	Inconsistent results in peer-reviewed literature; limited follow-up

Term	Definition
Conservative Therapy	A multimodal plan including active (eg, PT, OT, HEP, chiropractic) and inactive (eg, rest, ice, heat, TENS, pharmacotherapy) therapies.
HEP	A 6-week physician-supervised home exercise program requiring exercise prescription and follow-up or documented inability to complete for clinical reasons.
RFA	Percutaneous electrode under fluoroscopic guidance to thermocoagulate medial branches of dorsal spinal nerves.
SIJ Injections	Corticosteroid and local anesthetic therapeutic injections into the sacroiliac joint.

Revision History

2023-09-13added

Initial policy issued as new policy.

2025-01-29revisedLatest

Policy reviewed with updated references and approved at Committee; effective date 2025-05-01 and archived 2026-02-28. Review marked as non-material.