Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat sacroiliac (SI) joint injection services. 
 
You asked the Plan to pre-approve repeat (SI) joint injection services. You say that this injection is medically 
reasonable and necessary. The Plan denied your request. The Plan says the documentation does not support the 
first injection provided enough pain relief to warrant a second injection. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve repeat (SI) joint injection services. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the enrollee is a 47-year-old female with a history of sacroiliitis. She 
describes 6-9/10 low back pain which is described as sharp, stabbing, and radiates to both knees. On physical 
exam, Faber test is positive on the right, positive right Fortin test, positive right thigh thrust, and positive right 
Gaenslen. She has been treated with medical therapy and received right SI joint injections in December 2021 
and May 2022. Her provider has recommended a repeat right SI joint injection. 
 
Sacroiliac joint (SIJ) injections are recommended as an option if the patient has failed at least 4-6 weeks of 
aggressive conservative therapy including, physical therapy (PT), home exercise and medication management. There should be evidence of a clinical picture that is suggestive of sacroiliac injury and/or disease. At least 
three (3) positive exam findings of SI joint dysfunction should be present on physical exam such as: Patrick's 
test, thigh thrust, SI compression test, Yeoman's test, or Gaenslan's test.   
 
In this case, there is no documentation that there was at least 75% less pain and better function after the last 
injection to find the source of pain; or at least six weeks of 50% less pain and better function after the last 
injection to treat the pain.  There is lack of supportive documentation that the enrollee's performance has 
improved.  According to the coverage criteria:  "A positive response should demonstrate initial pain relief 
greater than or equal to (> /=) 75% -100% and the ability to perform previously painful maneuvers."  The 
review has determined that the requested repeat sacroiliac joint injection is not medically reasonable or 
necessary. 
 
In this case, the previous SI joint injection on 5/19/2022 provided only 30% pain relief for a period of 1 week. 
The review has determined that the items/services at issue in this case are not medically reasonable or 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of repeat (SI) joint injection services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve repeat sacroiliac (SI) joint injection services.