Changes coming for SI joint procedures

[Agast]

Email I received from ASIPP

LCD proposed changes for Medicare

https://files.constantcontact.com/be15115b001/f5af85f4-1d59-4e8f-a9c5-d97ffa2aa09c.pdf

Biggest change is primary Medicare will not be covering SI joint ablation. I think this is pretty cruel when I’ve had many patients rely on this 1-2 times a year with relief. I’d rather not send them for a fusion…

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[Agast]

What makes less sense to me is the verbiage regarding diagnostic and therapeutic SI joint injections. It almost makes it sound like you have to do an diagnostic first? What would that look like, a shot without steroid?


B. Diagnostic SIJIs
Diagnostic SIJI is used to determine if the etiology of pain is from the SIJ complex.3
Diagnostic SIJI are considered reasonable and necessary for patients who meet ALL the following criteria:
1. The patient must meet the above criteria for Covered Indications for SIJI, AND
2. The SIJI 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,6 AND
3. SIJI are not performed with other musculoskeletal injections in the lumbosacral spine, AND
4. The documentation should show direct causal benefit from the SIJI and not from other musculoskeletal injections or treatments, AND
5. 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 SIJI, 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.

Limitation: No more than 2 diagnostic joint sessions, unilateral or bilateral. To clarify, 2 unilateral sessions, if performed on 1 side at 1 session and on the opposite side at a different session, would meet the limitation of 2 diagnostic sessions.



Therapeutic SIJI
Therapeutic SIJI will be considered medically reasonable and necessary for patients who meet ALL the
following criteria:
1. The patient must meet the above criteria of Covered Indications for SIJI, AND
2. 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 SIJI, post-intervention on the day of the diagnostic injection, and the days following the diagnostic SIJI to substantiate and corroborate consistent pain relief for the duration of the local anesthetic and/or steroid used, AND
3. 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 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
4. The SIJIs must be performed under computed tomography (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.

Limitation: No more than 4 therapeutic SIJI sessions, unilateral or bilateral, will be reimbursed per rolling 12 months. To clarify, a therapeutic SIJI session if performed on 1 side first and then on the opposite side at a different session would qualify as 2 sessions for the frequency limitation of 4 therapeutic SIJ sessions per rolling 12 months.

 

[callmeanesthesia]

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

Sounds like you can call an injection of local anesthetic and steroid both diagnostic and therapeutic?

 

[Agast]

Sounds like you can call an injection of local anesthetic and steroid both diagnostic and therapeutic?

So if you’re allowed 2 diagnostic sessions and 4 therapeutic sessions, is that 6 SI joint injections a year? Shooting up every other month?

 

[GlowInTheDark]

What clowns come up with this stuff

 

[buddababa]

What clowns come up with this stuff

prolly primary care docs who dont understand things and are jealous of procedural specialties

 

[MitchLevi]

One of these days I will be forced out of pain and into a rehab facility.

This BS must cease.

 

[GlowInTheDark]

One of these days I will be forced out of pain and into a rehab facility.

This BS must cease.

It’s been said by someone else before…

I guess I’ll just change my practice to opioid only

 

[nvrsumr]

Did assip plan on fighting or is the proposal fait accompli?

 

[Agast]

Did assip plan on fighting or is the proposal fait accompli?

“
The policy does not show any major requirement changes, but it does tighten all the requirements, like facet joint injections. However, there is one problematic change related to sacroiliac joint radiofrequency neurotomy. In this proposed policy, this is considered as investigational and not covered.



ASIPP will be sending the comment letter within the comment period. If you would like to comment, please make sure that you comment prior to the deadline.



Again, the comment period on the proposed LCD for Sacroiliac Joint Injections and Procedures (DL39402) through Palmetto ends on October 15, 2022. Other Medicare Contractors’ comment closing dates are soon after.

Please see the table on the ASIPPwebsite with the Medicare Contractors, comment period and public meeting dates, links, etc.





Here is the link to submit comments to Palmetto and view the LCD. Click here.



We will continue to update you on the future comment dates and public meetings. “

 

[bedrock]

What clowns come up with this stuff

pure idiocy.

So they want to pay for two SIJ injections now instead of one? A diagnosis and steroid injection? I will just coach my patients to lie so I can do the real one.

reminds of insurance that want me to do 5 tests before doing an SIJ injection. So I have the patient come back for another visit, for 2 minutes, do the tests, I bill a 99214 out of spite, and so their insurance paid an extra $125.....and they still have to pay for the SIJ injection!

And eliminating SIJ ablations is just terrible. I hate that commercial insurance no longer covers that.

A bit worried that they don't want to cover other injections near the SIJ as I have billing billing an SIJ ligament injection for years. Might just make the patient come back for two different injections, so the ******* insurance can pay for another 2 things!

 

[clubdeac]

SIJ ablation with cooled technology is one of the most rewarding procedures I do. Works amazingly well. What a bunch of *****s

 

[Ducttape]

i remember the day - what, 4 years ago - when SI ablations were investigational.


this is just turning back the clock.

hopefully ASIPP has the data to show that SI ablations provide clinically meaningful improvement and can present it to CMS.

 

[Welcome123]

Sounds like you can call an injection of local anesthetic and steroid both diagnostic and therapeutic?

In the past and in reality that is true. Now, you have to check with the specific carrier

 

[Dr. Ice]

SIJ pathology is highly over diagnosed anyway…

 

[nvrsumr]

I find SIJ as under diagnosed especially by docs that only do procedures in ASCs

 

[bedrock]

SIJ pathology is highly over diagnosed anyway…

by physical therapists/chiropractors.

I only do around 4-5 SIJ injections per month out of my 245 monthly fluoro guided spine procedures.

 

[Dr. Ice]

I find SIJ as under diagnosed especially by docs that only do procedures in ASCs

Funny I find it over diagnosed by said docs who want to fuse the thing..”corner loc em”

 

[oreosandsake]

When people point to the sacral sulcus I think it’s either L5 facet or SIJ. Pain doesn’t radiate past the knee… you can try all those Laslet et al manuevers if you want. Diagnostic injection helps ddx

 

[Drd105]

What makes less sense to me is the verbiage regarding diagnostic and therapeutic SI joint injections. It almost makes it sound like you have to do an diagnostic first? What would that look like, a shot without steroid?


B. Diagnostic SIJIs
Diagnostic SIJI is used to determine if the etiology of pain is from the SIJ complex.3
Diagnostic SIJI are considered reasonable and necessary for patients who meet ALL the following criteria:
1. The patient must meet the above criteria for Covered Indications for SIJI, AND
2. The SIJI 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,6 AND
3. SIJI are not performed with other musculoskeletal injections in the lumbosacral spine, AND
4. The documentation should show direct causal benefit from the SIJI and not from other musculoskeletal injections or treatments, AND
5. 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 SIJI, 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.

Limitation: No more than 2 diagnostic joint sessions, unilateral or bilateral. To clarify, 2 unilateral sessions, if performed on 1 side at 1 session and on the opposite side at a different session, would meet the limitation of 2 diagnostic sessions.



Therapeutic SIJI
Therapeutic SIJI will be considered medically reasonable and necessary for patients who meet ALL the
following criteria:
1. The patient must meet the above criteria of Covered Indications for SIJI, AND
2. 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 SIJI, post-intervention on the day of the diagnostic injection, and the days following the diagnostic SIJI to substantiate and corroborate consistent pain relief for the duration of the local anesthetic and/or steroid used, AND
3. 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 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
4. The SIJIs must be performed under computed tomography (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.

Limitation: No more than 4 therapeutic SIJI sessions, unilateral or bilateral, will be reimbursed per rolling 12 months. To clarify, a therapeutic SIJI session if performed on 1 side first and then on the opposite side at a different session would qualify as 2 sessions for the frequency limitation of 4 therapeutic SIJ sessions per rolling 12 months.

This sounds to me like initially they want you to do the diagnostic (I knew a guy who did this: lido only) first, then you get up to 4 per 12 mos with steroid, so total of 10 sticks for bil or 5 sticks with unilat… does anyone else agree? And will there be a diagnostic modifier so they don’t take away from my steroid sticks?

 

[Drd105]

What makes less sense to me is the verbiage regarding diagnostic and therapeutic SI joint injections. It almost makes it sound like you have to do an diagnostic first? What would that look like, a shot without steroid?


B. Diagnostic SIJIs
Diagnostic SIJI is used to determine if the etiology of pain is from the SIJ complex.3
Diagnostic SIJI are considered reasonable and necessary for patients who meet ALL the following criteria:
1. The patient must meet the above criteria for Covered Indications for SIJI, AND
2. The SIJI 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,6 AND
3. SIJI are not performed with other musculoskeletal injections in the lumbosacral spine, AND
4. The documentation should show direct causal benefit from the SIJI and not from other musculoskeletal injections or treatments, AND
5. 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 SIJI, 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.

Limitation: No more than 2 diagnostic joint sessions, unilateral or bilateral. To clarify, 2 unilateral sessions, if performed on 1 side at 1 session and on the opposite side at a different session, would meet the limitation of 2 diagnostic sessions.



Therapeutic SIJI
Therapeutic SIJI will be considered medically reasonable and necessary for patients who meet ALL the
following criteria:
1. The patient must meet the above criteria of Covered Indications for SIJI, AND
2. 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 SIJI, post-intervention on the day of the diagnostic injection, and the days following the diagnostic SIJI to substantiate and corroborate consistent pain relief for the duration of the local anesthetic and/or steroid used, AND
3. 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 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
4. The SIJIs must be performed under computed tomography (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.

Limitation: No more than 4 therapeutic SIJI sessions, unilateral or bilateral, will be reimbursed per rolling 12 months. To clarify, a therapeutic SIJI session if performed on 1 side first and then on the opposite side at a different session would qualify as 2 sessions for the frequency limitation of 4 therapeutic SIJ sessions per rolling 12 months.

Disgusting, btw. I knew something along these lines was coming but surprised it is to this degree of stupid.

 

[paindoctor2014]

I can’t get georgia bcbs or medicair to cover rfa now. One of the most successful procedures I do.

 

[Ducttape]

this study illustrates some key points.

Radiofrequency Ablation as an Effective Long-Term Treatment for Chronic Sacroiliac Joint Pain: A Systematic Review of Randomized Controlled Trials

Radiofrequency ablation (RFA) has emerged as a popular intervention for chronic pain management, including pain originating in the sacroiliac joint. It offers a less invasive option than surgery but with better results than the previous standard ...

www.ncbi.nlm.nih.gov

on first glance, it suggests that RFA SI joints is beneficial.

but as you dive deeper, drusso's point about meta-analysis comes screaming out - GIGO.

out of all those studies included in the analysis, only 3 (Zheng, Patel and Salman, maybe Cohen) are really decent studies looking at whether si RFA is beneficial. this meta-analysis should have only discussed those 3 articles.

but then, 3 studies out of the 96 that were initially looked at is pretty crappy.....

we need more studies to convince CMS to reverse their decision....

 

[Dr. Ice]

Bilateral SIJ prp on a 40 year old dude who’s been through everything including sij rfa without benefit. Reviewed needle placement and report from doc who did rfa. Looked legit. Patient refused corner loc or whatever nonsense metal some docs wanted to put across the joint.

He’s 2 months out from PRP and he is 90% relieved. Able to bike, hike, run. Wasn’t able to do any of it for years.

Another 65 year old marathon runner with hip labral tear, surprisingly decent anatomy of hip otherwise, PRP..2 months out..no pain in groin, able to run, climb, no usage of any meds. He’s considering training for another marathon soon

 

[DrMDAware]

Why are we injecting the joint with a diagnostic block when the RFA is targeting the lateral branches of S1 S2 and S3?

Seems to me we should do a diagnostic block at the lateral branches of S1 S2 and 3 in order I have a better predictive value of the RFA.

I can see why a therapeutic injection is in the joint, though.

Thoughts?

 

[drusso]

this study illustrates some key points.

Radiofrequency Ablation as an Effective Long-Term Treatment for Chronic Sacroiliac Joint Pain: A Systematic Review of Randomized Controlled Trials

Radiofrequency ablation (RFA) has emerged as a popular intervention for chronic pain management, including pain originating in the sacroiliac joint. It offers a less invasive option than surgery but with better results than the previous standard ...

www.ncbi.nlm.nih.gov

on first glance, it suggests that RFA SI joints is beneficial.

but as you dive deeper, drusso's point about meta-analysis comes screaming out - GIGO.

out of all those studies included in the analysis, only 3 (Zheng, Patel and Salman, maybe Cohen) are really decent studies looking at whether si RFA is beneficial. this meta-analysis should have only discussed those 3 articles.

but then, 3 studies out of the 96 that were initially looked at is pretty crappy.....

we need more studies to convince CMS to reverse their decision....

You consistently miss the point about the limitations of meta-analysis for health policy. When meta-analysis (or multiple meta-analyses) consistently show a positive effect (especially across studies using similar protocols, indications, and methods), the findings are probably true. There is a signal in the noise. Think PRP.

However, when meta-analysis shows no effect, you CAN NOT conclude "the treatment doesn't work." You cannot prove the null hypothesis. This is because you can't improve the quality of dog crap by aggregating it. Aggregating bad studies only makes the overall methodological quality of the meta-analysis the same or worse. You just get more dog crap, not better dog crap.

Big Data: The Danger in Knowing Less and Less about More and More | The Lund Report

If policymakers want clearer direction about how to prioritize limited resources, then they can stop paying for meta-analysis.

www.thelundreport.org

"Thus, the real danger of meta-analysis is putting a premature end to a discussion based upon biased interpretation cloaked in quantitative authority. Contrary to the ideal of policymakers carefully weighing all evidence on complex issues before making rules and allocating resources, all too often policymakers have used research politically, selectively drawing on evidence to support already held views."

Thus, making a decision to pay for a treatment based on a meta-analysis that showed positive effects would be wise if the studies were of similar quality, etc. Refusing to pay for a treatment based on a meta-analysis that showed NO effect would be stupid because it could be that the underlying source studies were just dog crap. Aggregating them didn't help.

 

[Taus]

Why are we injecting the joint with a diagnostic block when the RFA is targeting the lateral branches of S1 S2 and S3?

Seems to me we should do a diagnostic block at the lateral branches of S1 S2 and 3 in order I have a better predictive value of the RFA.

I can see why a therapeutic injection is in the joint, though.

Thoughts?

Lateral branch block prior to lateral branch rfa is standard of care. If you were taught otherwise then that was incorrect.

One of the reasons outcomes in a bunch of the earlier SI RFA studies are garbage. No prognostic value was obtained prior to rfa.

 

[Tboned]

Why are we injecting the joint with a diagnostic block when the RFA is targeting the lateral branches of S1 S2 and S3?

Seems to me we should do a diagnostic block at the lateral branches of S1 S2 and 3 in order I have a better predictive value of the RFA.

I can see why a therapeutic injection is in the joint, though.

Thoughts?

I always do lateral branch blocks prior to SIJ RFA. Do bipolar palisade technique and try to get close to foramen. Outcomes pretty good, definitely not a home run every time.

Anyone else do LBB?

 

[Ducttape]

You consistently miss the point about the limitations of meta-analysis for health policy. When meta-analysis (or multiple meta-analyses) consistently show a positive effect (especially across studies using similar protocols, indications, and methods), the findings are probably true. There is a signal in the noise. Think PRP.

However, when meta-analysis shows no effect, you CAN NOT conclude "the treatment doesn't work." You cannot prove the null hypothesis. This is because you can't improve the quality of dog crap by aggregating it. Aggregating bad studies only makes the overall methodological quality of the meta-analysis the same or worse. You just get more dog crap, not better dog crap.

Big Data: The Danger in Knowing Less and Less about More and More | The Lund Report

If policymakers want clearer direction about how to prioritize limited resources, then they can stop paying for meta-analysis.

www.thelundreport.org

"Thus, the real danger of meta-analysis is putting a premature end to a discussion based upon biased interpretation cloaked in quantitative authority. Contrary to the ideal of policymakers carefully weighing all evidence on complex issues before making rules and allocating resources, all too often policymakers have used research politically, selectively drawing on evidence to support already held views."

Thus, making a decision to pay for a treatment based on a meta-analysis that showed positive effects would be wise if the studies were of similar quality, etc. Refusing to pay for a treatment based on a meta-analysis that showed NO effect would be stupid because it could be that the underlying source studies were just dog crap. Aggregating them didn't help.

you cant have it both ways. sorry. it doesnt work that way.

when you make a meta-analysis of dog crap, you still get.... dog crap. when you use really smelly (ie positive) dog crap, you get really smelly (ie positive) dog crap too.

maybe you confused me for someone else who advocates using meta-analysis to determine policy. if so, you have not read any single one of the posts i have made about meta-analysis.

 

[Ducttape]

Bilateral SIJ prp on a 40 year old dude who’s been through everything including sij rfa without benefit. Reviewed needle placement and report from doc who did rfa. Looked legit. Patient refused corner loc or whatever nonsense metal some docs wanted to put across the joint.

He’s 2 months out from PRP and he is 90% relieved. Able to bike, hike, run. Wasn’t able to do any of it for years.

Another 65 year old marathon runner with hip labral tear, surprisingly decent anatomy of hip otherwise, PRP..2 months out..no pain in groin, able to run, climb, no usage of any meds. He’s considering training for another marathon soon

good for them, but case reports are one of the lowest levels of clinical evidence. level VIII.

we need to be striving for level 1.

 

[RoloTomassi]

Everyone should be doing LBB before RFA. I do x2 like MBB.

64451

INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)

 

[DrMDAware]

So then are you using a different CPT for a SIJ injection?

 

[RoloTomassi]

So then are you using a different CPT for a SIJ injection?

27096

 

[drusso]

you cant have it both ways. sorry. it doesnt work that way.

when you make a meta-analysis of dog crap, you still get.... dog crap. when you use really smelly (ie positive) dog crap, you get really smelly (ie positive) dog crap too.

maybe you confused me for someone else who advocates using meta-analysis to determine policy. if so, you have not read any single one of the posts i have made about meta-analysis.

You're wrong. Yes, it does. Start here:

Detection theory - Wikipedia

en.wikipedia.org

 

[Ducttape]

You're wrong. Yes, it does. Start here:

Detection theory - Wikipedia

en.wikipedia.org

i think all you need is a nose and eyes to detect dog crap.

regardless, you cant have it both ways. you cannot say that, all things being equal with good meta-analyses, that favorable results require recognition of the treatment as effective and while negative results are to be summarily dismissed. this is bias.

 

[drusso]

i think all you need is a nose and eyes to detect dog crap.

regardless, you cant have it both ways. you cannot say that, all things being equal with good meta-analyses, that favorable results require recognition of the treatment as effective and while negative results are to be summarily dismissed. this is bias.

You know I have a master's degree in this topic, right? You can't win.

When MA finds an effect, it is likely true (statistically speaking, absent methodological flaws, etc). When MA does NOT find an effect all you can say is, "I'm still confused but on a higher level and about more important things." You can't make any statements about the truth.

 

[cowboydoc]

You know I have a master's degree in this topic, right? You can't win.

When MA finds an effect, it is likely true (statistically speaking, absent methodological flaws, etc). When MA does NOT find an effect all you can say is, "I'm still confused but on a higher level and about more important things." You can't make any statements about the truth.

you know he went to 7 residencies, right.

 

[oreosandsake]

you know he went to 7 residencies, right.

SDN U

 

[deleted131481]

Everyone should be doing LBB before RFA. I do x2 like MBB.

64451

INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)

I am not doing this currently but have thought I should. Considering starting with SIJ injection with steroid. If short-lived, then lateral mbb x1 before RFTC. I routinely do L5dr also with the lateral branches.

Edit: which insurance will cover SI RFTC seems to be a moving target. Anyone get lateral mbb approved but SI RFTC denied?

 

[Agast]

I am not doing this currently but have thought I should. Considering starting with SIJ injection with steroid. If short-lived, then lateral mbb x1 before RFTC. I routinely do L5dr also with the lateral branches.

Edit: which insurance will cover SI RFTC seems to be a moving target. Anyone get lateral mbb approved but SI RFTC denied?

Only Medicare, and with the upcoming change it will become Nobody

 

[MitchLevi]

I'd recommend you consider L4-S1 MBB/RFA and just add the S1 LB. That's what I'll be doing most likely. Some pts I may just do L4 MB, L5 DPR and S1 LB. Bill for one level and at least get paid for that.

 

[RoloTomassi]

I am not doing this currently but have thought I should. Considering starting with SIJ injection with steroid. If short-lived, then lateral mbb x1 before RFTC. I routinely do L5dr also with the lateral branches.

Edit: which insurance will cover SI RFTC seems to be a moving target. Anyone get lateral mbb approved but SI RFTC denied?

My algorithm is:
-SI IA steroid first
-If decent efficacy and duration, repeat prn
-If decent efficacy but short-lived, discuss LBBx2/RFA vs PRP
-If PRP not effective, then LBBx2/RFA

And yes, sometimes LBB approved but RFA not. Doesn't make sense. Sometimes LBB is not, so can self pay PRP or RFA

 

[Dr. Ice]

I stopped doing sij rfa a few years ago.

Mostly because well..I’m not a huge sij guy, probably because I was the lead author in Furman’s first book on Fluoro guided SIJ (the red one) and realized what it took to actually “be in” the joint..not to mention what I saw as an order over-dx.

Also a few years ago, I was told it wasn’t covered by a lot of private payors.

Have found peace with PRP for sij if they have gotten decent short term relief from intra-articular steroids

 

[nvrsumr]

I have been doing a lot more sij rfa this year. Will actually be a financial hit to my practice if it’s toast.

So arbitrary what is moved to “experimental”.

I’m not a smart stats guy and a solo doc so I feed the family based on my patients response to treatment.

If Medicare patients with zero secondary gain(ie no narcs practice) are lining up out the door to get repeats something is working. Maybe they just like to see baxter the shop dog.

 

[Agast]

I'd recommend you consider L4-S1 MBB/RFA and just add the S1 LB. That's what I'll be doing most likely. Some pts I may just do L4 MB, L5 DPR and S1 LB. Bill for one level and at least get paid for that.

Unfortunately a good number of my patients have both facet and SI joint pain, so I can see myself hamstrung by the q6 month/bilateral 2 level limit

 

[nvrsumr]

It has been great to have a non steroid option for SI joint. My Medicare patients end up getting 10 shots/yr by different docs not counting the oral steroids for whatever. Adds up and Medicare as usual can’t see the forest

 

[Ducttape]

You know I have a master's degree in this topic, right? You can't win.

When MA finds an effect, it is likely true (statistically speaking, absent methodological flaws, etc). When MA does NOT find an effect all you can say is, "I'm still confused but on a higher level and about more important things." You can't make any statements about the truth.

touting your "credentials" on a forum does little to justify your position. you do note the key issue - methodological flaws. most of the meta-analyses we have in pain have those, particularly with selection of studies. case in point is the meta-analysis listed above, and those that you have so delightfully called GIGO.

although i do admit, there are times where you have posted studies that clearly show that PRP has no benefit.

Unfortunately a good number of my patients have both facet and SI joint pain, so I can see myself hamstrung by the q6 month/bilateral 2 level limit

your RFA probably lasts for longer than 6 months. so at worst, do bilat L34 and L5S1 RFA, and throw in the S1 branch. you would really only not cover L12 and maybe L23...

mind you, i have not done this in the past year or so, so maybe now it would get denied.

SDN U

i learned more useful stuff from SDN U than my first residency.

 

[nvrsumr]

Does anyone know if SI ablations will be covered next year? The code is still listed on the medicare 2023 fee schedule.