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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say SACROILIAC (SI) JOINT INJECTIONS 
 
The sacroiliac (SI) joint is a diarthrodial, synovial joint which is formed by the articular surfaces of the sacrum 
and iliac bones. The SI joints bear the weight of the trunk and as a result are subject to the development of 
strain and/or pain. 
 
Indications for Sacroiliac (SI) Joint Injections: 
 
Sacroiliac (SI) joint injections would be considered medically reasonable and necessary for the diagnosis 
and/or treatment of chronic low back pain that is considered to be secondary to suspected sacroiliac joint 
dysfunction. Diagnostic and therapeutic injections of the SI joint would not likely be performed unless 
conservative therapy and noninvasive treatments (i.e., rest, physical therapy, NSAIDs, etc.) have failed.  
 
Diagnostic blocks of a sacroiliac joint can be performed to determine whether it is the source of low back pain. 
Arthropathy (joint disease) is diagnosed through a double-comparative local anesthetic blockade of the joint by 
the intra-articular injection of a small volume of local anesthetics of different durations of actions. A positive 
response should demonstrate initial pain relief greater than or equal to (> /=) 75% - 100% and the ability to 
perform previously painful maneuvers. Steroids may be injected in addition to the local anesthetic.  
 
Therapeutic sacroiliac (SI) joint injections of an anesthetic and/or steroid to block the joint for immediate, and 
potentially long lasting, pain relief are considered medically reasonable and necessary if it is determined that 
the SI joint is the source of pain in the lower back. The local anesthetic used for the procedure should not be 
billed. 
 
SI joint arthrography and/or therapeutic injection of an anesthetic/steroid should only be reported when 
imaging confirmation of intra-articular needle positioning with applicable radiological and/or fluoroscopic 
procedures have been performed. 
 
Limitations for Sacroiliac (SI) Joint Injections: 
 
If previous diagnostic or therapeutic SI injections of an anesthetic and/or steroid to block the joint for 
immediate, and potentially long lasting, pain relief have not effectively relieved the pain, further injections 
would not be considered medically necessary. 
 
Radiofrequency ablation used for sacro-iliac joint pain is considered not medically necessary/investigational 
whether performed using traditional, cooled, or pulsed radiofrequency. 
 
LIMITATIONS FOR ALL PAIN MANAGEMENT SERVICES 
 
General anesthesia or monitored anesthesia care (MAC) is rarely, if ever required for injections addressed in 
this policy. In fact, general anesthesia is contraindicated for diagnostic blocks (Manchikanti et al, 2005). 
 
 
Further, monitored anesthesia care or heavy sedation may provide false-positive results. 
 
Frequency and Number of Injections or Interventions: 
 
    In the diagnostic phase, a patient may receive injections at intervals of no sooner than one week or 
preferably, two weeks.  
    The number of injections in the diagnostic phase should be limited to no more than two times.  
    Once a structure is proven to be negative, no repeat interventions should be directed at that structure unless 
there is a new clinical presentation with symptoms, signs, and diagnostic studies of known reliability and 
validity that implicate the structure.  
    The effect of injected corticosteroids may remain for several weeks. The benefit is attributed to a decrease of 
local inflammation and perhaps some local anesthetic effect. It is usually not necessary to repeat an injection if 
there has been a satisfactory response to the first injection. Patients who relapse after a satisfactory response 
may be candidates for another trial after an appropriate interval. Consideration should be given to the 
cumulative dose injected and limitations made to avoid steroid complications.  
    In the therapeutic phase (after the diagnostic phase is completed), the frequency should be two months or 
longer between each injection, provided that there is initial pain relief with diagnostic injections of greater than 
or equal to (>/=) 75% - 100% with the ability to perform previously painful maneuvers, and a persistent pain 
relief of greater than or equal to (>/=) 50% with the continued ability to perform previously painful maneuvers 
is maintained for at least six weeks. The therapeutic frequency must remain at least two months or longer.  
    In the treatment or therapeutic phase, the injections should be repeated only as medically necessary. No more 
than four per patient per year are anticipated for the majority of patients.  
    Only sacroiliac joints for which there has been a positive response should be injected for therapeutic reasons. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Pain Management 
(L33622) and Local Coverage Article: Billing and Coding: Pain Management (A52863). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.