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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.

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:

1. The patient must meet the above criteria for Covered Indications for SIJI, AND
2. 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
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 greater than or equal to 75%
sustained and constant pain relief for the duration of the local anesthetic and greater than or 
equal to 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.

Therapeutic SIJI will be considered medically reasonable and necessary for patients who meet ALL the following criteria:

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 greater than or equal to 75% sustained and constant 
pain relief for the duration of the local anesthetic and greater than or equal to 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 SIJ injection, post-intervention on the day of the diagnostic injection, and the days 
following the diagnostic SIJ injection 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 
three (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 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.

Limitations: No more than four (4) therapeutic SIJI sessions, unilateral or bilateral, will be reimbursed per rolling 12 months. To clarify, a therapeutic SIJI session if performed on one side first and then on the opposite side at a different session would qualify as two (2) sessions for the limitation of four (4) therapeutic SIJ sessions per rolling 12 months.

SIJ Denervation (also called Radiofrequency Ablation or RFA) is not considered reasonable and necessary.

You can find these rules 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.