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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 state that sacroiliac joint injections (SIJIs) will be considered medically reasonable and necessary 
when all the following requirements are met: 
 
        Moderate to severe LBP primarily experienced over the anatomical location of the SIJs between the upper 
level of the iliac crests and the gluteal fold, AND 
        LBP duration of at least 3 months, AND 
        LBP 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 3 positive findings with provocative maneuvers: FABER, Gaenslen, Thigh Thrust or Posterior 
Shear, SI Compression, SI Distraction and Yeoman Tests,3,4 AND 
        LBP persists despite a minimum of 4 weeks of conservative therapies.5 
 
B. Diagnostic SIJIs 
 
          Diagnostic SIJI is used to determine if the etiology of pain is from the SIJ complex.3 
 
          Diagnostic SIJI are considered reasonable and necessary for patients who meet ALL the following 
criteria: 
 
        The patient must meet the above criteria for Covered Indications for SIJI, AND 
        The SIJIs must be performed under computed tomography (CT) or fluoroscopy image guidance with 
contrast, except ultrasound guidance may be considered reasonable and necessary when there is a documented 
contrast allergy or pregnancy, since the accuracy with ultrasound guidance is inferior to fluoroscopic 
guidance,6 AND 
        SIJI are not performed with other musculoskeletal injections in the lumbosacral spine, AND 
        The documentation should show direct causal benefit from the SIJI and not from other musculoskeletal injections or treatments, AND 
        The diagnostic SIJI provided a minimum of 75% relief of primary (index) pain with the diagnostic SIJI (a 
positive diagnostic response is defined as =75% sustained and constant pain relief for the duration of the local 
anesthetic and =75% sustained and constant pain relief for the duration of the anti-inflammatory steroid) was 
measured by the SAME pain scale* at baseline. The measurements of pain must be taken pre-injection on the 
day of the SIJI, post-intervention on the day of the injection, and the days following the injection to 
substantiate and corroborate the pain scores consistent with the pain relief for the duration of the local 
anesthetic and/or steroid used. 
 
Limitation: No more than 2 diagnostic joint sessions, unilateral or bilateral. To clarify, 2 unilateral sessions, if 
performed on 1 side at 1 session and on the opposite side at a different session, would meet the limitation of 2 
diagnostic sessions. 
 
You can find this information in the Local Coverage Determination (LCD) Sacroiliac Joint Injections and 
Procedures L39402. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.