Los Angeles Sacroiliac Joint Fusion (SI Joint Fusion) Surgery Denial Lawyer
The sacroiliac joint, also known as the “SI joint,” is located at the bottom of the spine. This joint connects the sacrum (tailbone) to the pelvis. It is where the sacrum meets the ilium (hip) bones at the base of your spine. A network of muscles that assist the pelvic bones support this joint. The SI joint helps with stability, acting as a shock absorber between the lower and upper parts of the body. This joint usually only moves a small amount. But when it moves too little or too much, the resulting dysfunction is sometimes incredibly painful. Unfortunately, because symptoms are similar to other conditions, SI joint dysfunction can be hard to diagnose.
This article reviews SI joint dysfunction, diagnosis, and treatments for the condition. It covers the minimally invasive surgery known as “SI joint fusion” as well as information about this procedure. Finally, it discusses how health insurance companies review member claims for SI joint fusion surgery. If you receive a health insurance denial for SI joint fusion, call the Law Offices of Scott Glovsky and we can help.
What is SI Joint Dysfunction?
SI joint dysfunction has other names including SI joint syndrome, SI joint strain, SI joint inflammation, and SI joint pain. It occurs when there is too little or too much movement of this joint. Too much movement can occur in pregnancy or if there is an injury to the nearby ligaments. Too little movement may occur with arthritis or other joint degenerative diseases. Dysfunction typically happens on one side although it may appear on both sides. Dysfunction may result in inflammation of the joints (“sacroiliitis”) or in pain in the lower back, buttocks, or legs. Sometimes there is also pain in nearby muscles.
What Causes SI Joint Dysfunction?
Dysfunction in this joint may stem from an injury or fall, car crash, pregnancy, or a laminectomy, or lumbar fusion. Pain comes with irregular pelvic movement. What leads to this movement? It might be hip or knee issues, arthritis, or even shoes without proper support and wearing a boot after surgery.
How Do You Know If You Have Sacroiliac Joint Dysfunction?
You may have SI joint dysfunction if you have pain in the lower back, hips, or buttocks. Pain can also come in the groin area and/or the side or back of the thigh. Sometimes that pain may radiate down the back of your leg (sciatica). You may have a reduced range of motion in these areas that makes it harder to bend or to walk upstairs. Or you may feel stiffness and lowered mobility. You may feel numbness or tingling or even weakness in the leg. Certain activities may intensify the pain like traveling in a car, running, or putting weight on one side. These activities can even include standing or walking for a long time or sleeping in certain positions. And you may feel unstable changing positions. Oftentimes this pain is so severe that it is difficult to perform activities of daily life.
How Does Your Doctor Diagnose SI Joint Dysfunction?
SI joint dysfunction symptoms are like other health problems such as hip issues or herniated discs. For this reason, it is sometimes hard to diagnose SI Joint Dysfunction. One study estimates that 15-25% of lower back pain stems from the sacroiliac joint. Orthopedic physicians, like other doctors, start with a medical history. They seek information about when the pain started, where it is, and if it is constant or sporadic.
These physicians also investigate diet and exercise routines. Doctors also conduct movement tests in which they apply pressure while moving a part of the body to diagnose issues. Movement tests include the FABER test, the Distraction test, the Sacral thrust test, and Palpitation tests. They may also do x-rays and a CT (computerized tomography) and/or MRI (magnetic resonance imaging) scan. The challenge with the imaging tests is that SI joint dysfunction doesn’t typically show up well on these tests. Finally, an injection test with an anesthetic can help decipher the cause of the pain. When the injection into the joint helps, it is likely that the SI joint is the source of the pain. Doctors use several tests since there is not a single test that can diagnose SI joint dysfunction on its own.
What Are Treatments For SI Joint Dysfunction?
Physicians usually begin with non-surgical treatments. Treatments often include applying heat or ice. Sometimes they include pain medication. Pain medication can be over the counter (OTC) including acetaminophen (Tylenol®) and anti-inflammatories like ibuprofen (Advil®). More severe pain calls for prescription medications such as muscle relaxers or narcotic pain killers. Another common treatment involves movement. This treatment includes stretching exercises, physical therapy, and visits to a chiropractor. Sometimes doctors recommend wearing a brace around the pelvic area for support. And finally, injections with anti-inflammatories like cortisol can help relieve pain. But what if these treatments don’t resolve SI joint dysfunction?
What Is SI Joint Fusion?
When other treatments don’t help SI joint dysfunction, doctors may recommend the minimally invasive surgery called, “SI joint fusion.” This surgery is not new. The surgery and the implant system called iFuse was approved by the FDA in 2009 and has been performed over 45,000 times. In this elective procedure, surgeons enter the body through the back, fusing the sacroiliac bone to the ilium and the sacrum. A bone graft and possibly also instruments encourage bone growth over the SI joint making a single, immobile unit.
Most procedures only require a few days in the hospital. Some are outpatient procedures that don’t even require a night in the hospital. Recovery time can be as little as 3 months or as many as 6 months. During recovery, patients use pain medications, heat and ice, and physical therapy. Patients usually use crutches to avoid putting weight on the joint. Doctors may also want patients to use a pelvic brace during for support this period.
Are There SI Joint Fusion Complications?
Like any other surgery, there is always a risk that the procedure doesn’t work. Another risk is that pressure from the SI joint will simply move to the lower back. There might be stress to the pelvic bones adjacent to the fusion. This is what’s known as, “adjacent segment disease.” And another surgery might be required to make adjustments. But the reality is that SI joint fusion surgeries are highly effective. A study of the iFuse implant from SI-Bone, Inc. was published in 2016. Published in the International Journal of Spine Surgery, the study showed the procedure is highly effective. It reduced pain in 77% to 85% of people and improved disability in 59% to 75% of people. In fact, there are over 80 published, peer-reviewed articles that speak to the safety and efficacy of SI joint fusions.
Do Health Insurers Cover SI Joint Fusion?
The standard of care for SI joint dysfunction is SI joint fusion. The premier spine surgeon associations in the United States consider the procedure medically necessary and not investigational. Many of the major health plans cover this surgery. But some health insurance plans do not cover SI joint fusion because they claim it is investigational. Why are there discrepancies in coverage from different health plans? Because each health insurer sets its own policy with internal clinical guidelines for when treatment is considered medically necessary. So Anthem Blue Cross, Blue Shield, Aetna, Cigna, Kaiser, Health Net, UnitedHealthcare, Oscar, Magellan, Molina, and others have different plans. Policies are often created internally and evaluated by external doctors who choose whether the specific policy is correct. But the process may include incentives to deem a policy correct when in fact it is overly restricting. For example, often the external doctors are paid by the insurer. These doctors may want to eventually work for the health insurer. And corporations like insurance companies have incentives not to include expensive treatments because the cost impacts their bottom line.
What Can You Do If You Receive a Health Insurance Denial for SI Joint Fusion From Your Insurance Company?
You have many options if your insurer denies this procedure, starting with appealing the denial. You first need to consider the type of plan you have. There are ERISA and non-ERISA plans. ERISA stands for “Employee Retirement Income Security Act of 1974.” If you receive your health insurance through your employer, you likely have an ERISA plan. ERISA protects the interests of individuals and their beneficiaries who receive health insurance from their employers. This law limits what an insurance policyholder can do.
But not all employer plans are considered ERISA plans. If your employer is the government or a religious institution, you have a non-ERISA plan. Or, if you have a business plan where the policy only covers the business owner, your plan is non-ERISA. If you purchased your plan directly through Covered California, your plan is non-ERISA. And finally, if you purchased your plan directly from an insurance company like Anthem Blue Cross, Blue Shield, Aetna, Cigna, Kaiser, Health Net, UnitedHealthcare, Oscar, Magellan and Molina, your plan is non-ERISA.
If you have an ERISA plan you should file an appeal because if you don’t, your future options are limited. We suggest you speak with an ERISA attorney before you submit the appeal.
If you have a non-ERISA plan, you have more options.
Should You Get a Health Insurance Attorney Involved to Fight your Health Insurance Denial?
We recommend you get a health insurance lawyer involved to help fight your denial. California dictates the process you need to follow and with some plans, the appeals process can include multiple steps. So, it is important to understand the many options available. In the end, you might need to sue your insurance company to get the treatment you need. A non-ERISA lawyer can help you get the procedure you need so you start feeling better sooner.
How to Select a Health Insurance Lawyer?
Dealing with insurance companies can be frustrating and time-consuming. You want to hire an attorney who focuses on health insurance cases and who understands insurers’ systems. A lawyer who has worked on the other side representing insurance companies knows them best. And an attorney who has litigated the same types of cases can offer your highest chance of success.
Contact Law Offices of Scott Glovsky if You Receive a SI Joint Fusion Health Insurance Denial
The Law Offices of Scott Glovsky has represented injured consumers and victims of wrongful business practices for more than the past two decades. The firm focuses on health insurance bad faith, catastrophic personal injury, sexual abuse, and consumer-related litigation. We have litigated cases against health insurers arising from the denial of SI joint fusion surgeries. And we work on contingency, meaning you don’t pay us anything until and unless we win your case.