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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 (SIJI) will be considered medically reasonable and necessary 
when all the following requirements are met: 
 
  
  1. 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 
2. Low back pain duration of at least three (3) months, AND 
3. Low back pain below L5 without radiculopathy, AND 
4. 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 
5. At least three positive findings with provocative maneuvers: FABER, Gaenslen, Thigh Thrust or 
Posterior Shear, SI Compression, SI Distraction and Yeoman Tests, AND 
6. Low back pain persists despite a minimum of four weeks of conservative therapies. 
 
B. Diagnostic Sacroiliac Joint Injections: Diagnostic SIJI are used to determine if the etiology of pain is from 
the sacroiliac joint complex. Diagnostic SIJI are considered reasonable and necessary for patients who meet 
ALL the following criteria: 
 
1. The patient must meet the above criteria for Covered Indications for SIJI, AND 
2. The SI joint injections must be performed under computed tomography 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, AND 
3. SI joint injection are not performed with other musculoskeletal injections in the lumbosacral 
spine, AND 
4. The documentation should show direct causal benefit from the SI joint injection and not from 
other musculoskeletal injections or treatments, AND 
5. 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 two (2) diagnostic joint sessions, unilateral or bilateral. To clarify, two unilateral 
sessions, if performed on one side at one session and on the opposite side at a different session, would meet the 
limitation of two (2) diagnostic sessions. 
 
You can find this information 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.