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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 say that low back pain (LBP) is highly prevalent in the Medicare population with reports of 50 to 
84% of adults experiencing back pain at some point and is the highest cause of disability globally. 
Approximately 15% to 30% of patients with persistent mechanical LBP below L5 have pain arising from their 
sacroiliac (SI) joints (SIJ). SIJ dysfunction is common after spinal fusion; and reported in up to 40% in some 
studies. The treatment of individuals with spinal disorders, including pain, can be complex, and it is 
recommended that all individuals being considered for interventional spinal procedures undergo a thorough 
evaluation and be treated following development of a comprehensive care plan. 
 
Sacroiliac joint injections (SIJI) will be considered medically reasonable and necessary when all the following 
requirements are met: 
 
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 
Low back pain duration of at least three (3) months, AND 
Low back pain 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 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 
Low back pain persists despite a minimum of four weeks of conservative therapies. 
 
Diagnostic Sacroiliac Joint Injections 
          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: 
The patient must meet the above criteria for Covered Indications for SIJI, AND 
The SI joint injections must be performed under computed 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 
SI joint injection are not performed with other musculoskeletal injections in the lumbosacral spine, AND 
The documentation should show direct causal benefit from the SI joint injection and not from other 
musculoskeletal injections or treatments, 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 =75% sustained and constant pain relief for the duration of the local 
anesthetic and =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. 
 
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) Sacroiliac Joint Injections and 
Procedures L39455. 
 
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.