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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 that low back pain (LBP) is highly prevalent in the Medicare population with reports of 50 to 
84% of adults experiencing back pain at some point and is the highest cause of disability globally. 
Approximately 15% to 30% of patients with persistent mechanical LBP below L5 have pain arising from their 
sacroiliac joints (SIJ). SIJ dysfunction is common after spinal fusion; and reported in up to 40% in some 
studies. The SIJ is a complex structure; it is a diarthrodial joint with matching articulate surfaces between the 
sacrum and ilium separated by synovial fluid and surrounded by a fibrous capsule. It is only a true synovial 
joint in the anterior portion, due to discontinuity of the posterior capsule. It serves as the biomechanical 
mediator between the spine and the pelvis. The joint is responsible for flexion and extension of the sacrum with 
counterrotation of the ileum and there is only a small amount of movement. The complexity of the joint is in 
the small degree of movement of the joint and the functional supporting structures of the joint (mainly the 
muscles, fascia and ligamentous connections). 
 
The sacroiliac (SI) joint goes through many changes throughout life. In early childhood, the surfaces of the 
joint are smooth and allow gliding motions in many directions. After puberty, the surface of the ilium becomes 
rougher and coated with fibrous plaques that will restrict motion significantly. These age-related changes will 
increase in the third and fourth decade and by the sixth decade motion may become noticeably restricted. By 
the eighth decade, plaque will form, and erosions will be present. The SI joint has variable joint capacity as the 
SI joint degenerates with age and has varied from 0.5-2.5 ml. 
 
The exact pattern of innervation of the joint is unclear, but the subchondral bone, capsule and surrounding 
ligaments are innervated by spinal nerves with nociceptor and proprioceptors and therefore can be a source of 
pain from the SIJ complex may arise from the posterior extraarticular elements that are innervated by the lateral 
branches of S1-S3 and L5 dorsal ramus or the anterior complex innervated by spinal nerves, branches of the 
gluteal and obturator nerves and lumbosacral trunks known as the intra-articular elements. The spectrum of 
pain and dysfunction from SIJ pain is variable but can be debilitating. 
 
 
 
 In addition to conservative and surgical modalities, interventional procedures are used for treatment of SIJ pain. 
This includes SIJ injections and radiofrequency (RFA) ablation of the SIJ joint. Injections typically are intra-
articular and contain anesthetic and corticosteroids. Ablation relies on radiofrequency-generated thermal 
energy to ablate the sensory nerve fibers of the sacroiliac joint, thereby interrupting nociceptive signals. 
 
The treatment of individuals with spinal disorders, including pain, can be complex, and it is recommended that 
all individuals being considered for interventional spinal procedures undergo a thorough evaluation and be 
treated following development of a comprehensive care plan. 
 
Covered Indications 
 
A. Sacroiliac joint injections (SIJI) will be considered medically reasonable and necessary when all the 
following requirements are met: 
 
        Moderate to severe low back pain primarily experienced over the anatomical location of the SI joints 
between the upper level of the iliac crests and the gluteal fold, AND 
        Low back pain duration of at least three (3) months, AND 
        Low back pain below L5 without radiculopathy, AND 
        Clinical findings and/or imaging studies do not suggest any other diagnosed or obvious cause of the 
lumbosacral pain (such as central spinal stenosis with neurogenic claudication/myelopathy, foraminal stenosis 
or disc herniation with concordant radicular pain/radiculopathy, infection, tumor, fracture, pseudoarthrosis, or 
pain related to spinal instrumentation), AND 
        At least three positive findings with provocative maneuvers: FABER, Gaenslen, Thigh Thrust or Posterior 
Shear, SI Compression, SI Distraction and Yeoman Tests, AND 
        Low back pain persists despite a minimum of four weeks of conservative therapies. 
 
You can find these rules in the Local Coverage Determination (LCD) Sacroiliac Joint Injections and 
Procedures L39455. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.