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 sacroiliac joint injection (SIJI) will be considered medically reasonable and necessary when 
all the following requirements are met: 
- Moderate to severe low 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, SI Compression, SI Distraction and Yeoman Tests, AND 
- LBP persists despite a minimum of 4 weeks of conservative therapies. 
Therapeutic SIJI will be considered medically reasonable and necessary for patients who meet ALL the 
following criteria: 
- The patient must meet the above criteria of Covered Indications for SIJI, AND 
- 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 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 
- 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 
- 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. 
You can find these rules in 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. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.