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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. 
 
B. Diagnostic Sacroiliac Joint Injections 
 
          Diagnostic SIJI is 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: 
 
The patient must meet the above criteria for Covered Indications for SIJI, AND 
The SI joint injections must be performed under 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, AND 
SI joint injection are not performed with other musculoskeletal injections in the lumbosacral spine, AND 
The documentation should show direct causal benefit from the SI joint injection 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 SIJ injection, 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 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.