Appeal type: unknown
Decision: unknown

 
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: 
A. SIJIs will be considered medically reasonable and necessary when all the following requirements are met: 
1. 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 
2. LBP duration of at least 3 months, AND 
3. LBP 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 3 positive findings with provocative maneuvers: FABER, Gaenslen, Thigh Thrust or 
Posterior Shear, SI Compression, SI Distraction and Yeoman Tests,
3,4
 AND 
6. 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. 
          Diagnostic SIJI are considered reasonable and necessary for patients who meet ALL the following 
criteria: 
1.  
1. The patient must meet the above criteria for Covered Indications for SIJI, AND 
2. 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,
 
AND 3. SIJI are not performed with other musculoskeletal injections in the lumbosacral spine, AND 
4. The documentation should show direct causal benefit from the SIJI 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 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. 
C. Therapeutic SIJI 
Therapeutic SIJI will be considered medically reasonable and necessary for patients who meet ALL the 
following criteria: 
1.  
1. The patient must meet the above criteria of Covered Indications for SIJI, AND 
2. 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 were taken pre-injection on the day of the diagnostic SIJI, post-
intervention on the day of the diagnostic injection, and the days following the diagnostic SIJI to 
substantiate and corroborate consistent pain relief for the duration of the local anesthetic and/or 
steroid used, AND 
3. Subsequent therapeutic SIJI are considered medically reasonable and necessary when the 
subsequent SIJI are provided at the same anatomic site as therapeutic SIJI, AND the therapeutic 
SIJI produced at least consistent 50% pain relief or at least 50% consistent improvement in the 
ability to perform previously painful movements and activities of daily living (ADLs) for at 
least 3 months from the proximate therapeutic SIJI procedure and compared to baseline 
measurements for ADLS and painful movements or pain relief using the same pain scale* AND 
4. The SIJIs 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. 
Limitation: No more than 4 therapeutic SIJI sessions, unilateral or bilateral, will be reimbursed per rolling 12 
months. To clarify, a therapeutic SIJI session if performed on 1 side first and then on the opposite side at a 
different session would qualify as 2 sessions for the limitation of 4 therapeutic SIJ sessions per rolling 12 months. 
D. SIJ Denervation (also called Radiofrequency Ablation or RFA) is not considered reasonable and necessary. 
 
 Limitations 
1. Injections performed without radiographic image guidance are not considered reasonable and 
necessary.
6
 
2. A SIJI involves the use of an anesthetic, corticosteroid, and contrast agent and does not include 
injections of biologics (e.g., platelet rich plasma, stem cells, amniotic fluid, etc.) and/or any other 
injectates. 
3. It is not considered medically reasonable and necessary to perform multiple blocks (ESI, sympathetic 
blocks, facet blocks, trigger point injections, etc.) during the same session as SIJIs and during the post 
SIJI efficacy assessment period. 
4. Use of Moderate or Deep Sedation, General Anesthesia, and Monitored Anesthesia Care (MAC) is 
usually unnecessary or rarely indicated for SIJIs, and therefore, not considered medically reasonable 
and necessary.
10
 Even in patients with a needle phobia and anxiety, typically oral anxiolytics suffice.
9
 
5. SIJIs to treat non-specific LBP, axial spine pain primary above the level of L5, complex regional pain 
syndrome (CRPS), widespread diffuse pain, chronic pain syndrome, and pain from neuropathy are 
considered investigational, and therefore, are not considered medically reasonable and necessary. 
6. SIJIs used as part of a series of lumbar spine and musculoskeletal injections to treat nonspecific or 
chronic LBP is not considered reasonable and necessary. 
7. In patients with implanted electrical devices, (i.e., spinal cord stimulation, peripheral nerve stimulation, 
cardiac devices, etc.) and intrathecal pump delivery devices, providers should follow manufacturer 
instructions and extra planning as indicated to ensure safety of the procedure. 
8. Patients with coexisting psychological conditions or depression related illness should be treated and 
stabilized prior to proceeding with interventional procedures.
11
 Multidisciplinary biopsychosocial 
rehabilitation principles should be provided to these patients. 
9. It generally would not be considered medically reasonable and necessary for treatment with SIJIs to 
extend beyond 12 months. Frequent continuation of SIJIs over 12 months may trigger a focused 
medical review. Use beyond 12 months requires the following: 
a. Pain is severe enough to cause a significant degree of functional disability or vocational 
disability and providers use established and measurable goals and objective scales to assess 
functionality and ADLs measures. 
b. SIJIs provides at least 50% sustained and consistent improvement of pain and/or 50% sustained 
and consistent objective improvement in function (using same scale as baseline) for at least 3 
months. 
c. Rationale for the continuation of SIJIs, including but not limited to, patients who are high-risk 
surgical candidates, the patient does not desire surgery, and/or the recurrence of pain in the same 
location was sustained and consistently relieved with the SIJIs for at least 3 months. 
d. The primary care provider should be notified regarding continuation of procedures and 
prolonged repeat steroid use to allow for systematic care delivery treatment surveillance and 
multidisciplinary biopsychosocial rehabilitation (MBR). 
10. A subsequent diagnostic SIJI is not reasonable and necessary when the initial diagnostic block does not 
produce a positive response of  75% pain reduction. 
11. A subsequent therapeutic SIJI is not reasonable and necessary when the proximate SIJI did not provide 
at least a consistent 50% pain relief or at least a 50% consistent improvement in the ability to perform 
previously painful movements and ADLs for at least 3 months compared to baseline objective 
measurements for ADLS and painful movements or pain relief using the same pain scale.* 
You can find this rule at the Medicare Local Coverage Determination (LCD) L39402: Sacroiliac Joint 
Injections and Procedures. 
 
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.