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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 sacroiliac joint injections (SIJIs) will be considered medically reasonable and necessary 
when all the following requirements are met: 
 
        Moderate to severe lower back pain (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, sacroiliac (SI) Compression, SI Distraction and Yeoman Tests AND 
        LBP persists despite a minimum of 4 weeks of conservative therapies. 
 
E. Requirements 
 
    The SIJI must be performed under copmuterized tomography (CT) or fluoroscopy image guidance with 
contrast, unless the patient has a documented contrast allergy or pregnancy where ultrasound guidance without 
contrast may be considered. 
    The SIJ procedure(s) should be performed in conjunction with conservative treatments. 
    Patient should be part of an ongoing, and be actively participating in a rehabilitation program, home exercise 
program or functional restoration program 
    SIJ primary index pain must be measured prior to the injection at the beginning of the session. 
    The post procedure pain level must be measured after the SIJI at the conclusion of the session. 
    SIJI may be performed unilateral or bilateral if clinically indicated within the same session. 
    The documentation must have the radiographic films (i.e., fluoroscopy images) of the procedure in at least 2 views (i.e., the pre and post contrast injection views in the AP and oblique planes) to confirm intraarticular 
injection of contrast and the treatment agent(s) used. 
 
    When documenting the percentage of pain relief from the primary (index) pain compared to the post-
injection pain levels, it is insufficient to report only a percentage of pain relief and/or a nonspecific statement of 
the duration of pain relief. The documentation should include a specific assessment of the duration of relief 
being consistent or inconsistent with the agent used for the injection and the specific dates the measurements 
were obtained using the SAME pain scale* used at baseline. 
 
    When documenting the ability to perform previously painful movements and activities of daily living 
(ADLs) it is insufficient to provide a vague or nonspecific statement regarding the improvement of previously 
painful movements and ADLs. The documentation should include a functional assessment to show clinically 
meaningful improvement with painful movements and ADLs, if this metric is used to justify the efficacy of the 
SIJI procedure. Providers should use established and measurable goals and objective scales to assess 
functionality and ADLs measures. 
 
You can find this information in Medicare's 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.