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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 (SIJI) will be considered medically reasonable and necessary when 
all the following requirements are met: 
1.  
1. Moderate to severe low back pain primarily experienced over the anatomical location of the 
sacroiliac (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: Flexion Abduction External 
Rotation (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. 
The rules say that 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 SI joint injections must be performed under computerized 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. 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 was measured by the SAME pain scale at baseline. The measurements of pain 
must be taken pre-injection on the day of the sacroiliac joint (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 this information in the Local Coverage Determination (LCD) for Sacroiliac Joint Injections and 
Procedures (L39383). 
 
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.