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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 Neural blockade is one technique used in chronic pain management. Neural blockade is the 
interruption of neural transmission by the injection of a local anesthetic agent or other drug. Nerve block 
therapy can be used to answer specific questions resulting from a careful evaluation of the patient's pain 
problem and to gain insight into the underlying problem causing the pain. Success of the nerve block is 
determined by the adequacy of interruption of nerve function, and the effect of that blockade on the patient's 
pain. The goal of chronic pain management is to achieve optimal pain control, recognizing that a pain-free state 
may not be achievable; minimize adverse outcomes; enhance functional abilities and physical and 
psychological well-being; and enhance the quality of life for patients with chronic pain. 
 
The decision to treat chronic pain by invasive or destructive procedures must be based on a thorough evaluation 
of the patient and include a systematic assessment of the location, intensity, and pathophysiology of the pain. A 
detailed pain history that includes prior treatment and response to treatment is essential. A detailed physical 
examination and review of all pertinent diagnostic tests is also needed. This local coverage determination 
documents National Government Services indications and limitations for pain management treatment. 
 
SACROILIAC (SI) JOINT INJECTIONS 
 
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. You can 
find this rule 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.