Draft — pending COA review. Rette derived these criteria from the ACOEM guidelines adopted into the MTUS. They are not COA documents and have not been signed off by a COA physician reviewer.

MTUS Treatment ChecklistbyRette

Utilization Review Checklist

Sacroiliac Joint Surgery for Low Back Pain

Derived from the ACOEM Low Back Disorders Guideline, edition 13 February 2020, as adopted into the California MTUS 23 November 2021. CPT 27279, 27280. ICD-10 M53.2X8, M46.1, M53.3.

Draft — not reviewed or approved by COA. Prepared by Rette from the ACOEM guideline named above. This is not a COA document and does not reproduce COA’s own checklists.

Patient name: Claim #:

CriteriaCheck if documented

Presumptive Diagnosis(informational — not scored)

Required

  • Low back pain disorder attributed to the sacroiliac joint

    “Sacroiliac joint fusion surgery and other sacroiliac joint surgical procedures are not recommended for treatment of low back pain disorder.” — p. 179

Procedures — the guideline treats each separately

Sacroiliac joint fusion or other sacroiliac joint surgical procedure for low back pain

Not Recommended. Sacroiliac joint fusion surgery and other sacroiliac joint surgical procedures are not recommended for treatment of low back pain disorder.

Strength of Evidence — Not Recommended, Insufficient Evidence (I) · confidence low · p. 179

Indications — required:

  • The guideline advises against sacroiliac joint fusion and other sacroiliac joint procedures for low back pain disorder

    “Sacroiliac joint fusion surgery and other sacroiliac joint surgical procedures are not recommended for treatment of low back pain disorder.” — p. 179

Not recommended. The recommendation is written broadly — fusion AND 'other sacroiliac joint surgical procedures' — so an alternative SI joint operation is covered by the same finding. The guideline states no indications and no exception.

Reviewing this for COA, or think a criterion is wrong?