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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 injection into tendon sheaths, their origins or insertions, ligaments, or ganglion cysts is 
indicated to relieve substantial pain and/or significant functional disability that results from inflammation or 
other pathological changes in those structures. Proper use of this modality should be part of an overall 
management plan including diagnostic evaluation in order to clearly identify and properly treat the primary 
cause. 
 
Other conservative therapy has not provided acceptable relief, is contraindicated, or not appropriate. 
 
There is a reasonable likelihood that injection will significantly improve the patient's pain and/or functional 
disability. 
 
Injection of a carpal tunnel may be indicated for the patient with mild to moderate symptoms when 
pharmaceutical and other conservative measures have failed or are not otherwise indicated. 
 
Injection of the tarsal tunnel may be indicated for conservative management of tarsal tunnel syndrome. 
 
When a given specific tendon, ligament, tunnel, or cyst is injected, it will be considered one injection service 
regardless of the number of injections administered at that specific anatomical location on a single date of 
service. 
 
The sacroiliac (SI) joint is a diarthrodial, synovial joint which is formed by the articular surfaces of the sacrum 
and iliac bones. The SI joints bear the weight of the trunk and as a result are subject to the development of 
strain and/or pain. 
 
Indications for Sacroiliac (SI) Joint Injections: 
 
Sacroiliac (SI) joint injections would be considered medically reasonable and necessary for the diagnosis 
and/or treatment of chronic low back pain that is considered to be secondary to suspected sacroiliac joint 
dysfunction. Diagnostic and therapeutic injections of the SI joint would not likely be performed unless 
conservative therapy and noninvasive treatments (i.e., rest, physical therapy, NSAIDs, etc.) have failed. 
 
Diagnostic blocks of a sacroiliac joint can be performed to determine whether it is the source of low back pain. 
Arthropathy (joint disease) is diagnosed through a double-comparative local anesthetic blockade of the joint by the intra-articular injection of a small volume of local anesthetics of different durations of actions. A positive 
response should demonstrate initial pain relief greater than or equal to (> /=) 75% - 100% and the ability to 
perform previously painful maneuvers. Steroids may be injected in addition to the local anesthetic. 
 
Therapeutic sacroiliac (SI) joint injections of an anesthetic and/or steroid to block the joint for immediate, and 
potentially long lasting, pain relief are considered medically reasonable and necessary if it is determined that 
the SI joint is the source of pain in the lower back. The local anesthetic used for the procedure should not be 
billed. 
 
SI joint arthrography and/or therapeutic injection of an anesthetic/steroid should only be reported when 
imaging confirmation of intra-articular needle positioning with applicable radiological and/or fluoroscopic 
procedures have been performed. 
 
Limitations for Sacroiliac (SI) Joint Injections: 
 
If previous diagnostic or therapeutic SI injections of an anesthetic and/or steroid to block the joint for 
immediate, and potentially long lasting, pain relief have not effectively relieved the pain, further injections 
would not be considered medically necessary. 
 
Radiofrequency ablation used for sacro-iliac joint pain is considered not medically necessary/investigational 
whether performed using traditional, cooled, or pulsed radiofrequency. 
 
You can find this information in the Local Coverage Determination (LCD) Pain Management L33622. 
 
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.