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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 acute pain is elicited by the injury of body tissues and activation of nociceptive transducers at 
the site of local tissue damage. This type of pain is often a reason to seek health care, and it occurs after trauma, 
surgical interventions, and some disease processes. 
 
Chronic pain has been defined as "persistent or episodic pain of duration or intensity that adversely affects the 
function or well-being of the patient, attributable to any nonmalignant etiology" ("Practice Guidelines for 
Chronic Pain Management: A Report by the American Society of Anesthesiologists Task Force on Pain 
Management, Chronic Pain Section"). In addition, the pain has been refractory to repeated attempts at medical 
management and usually has been present for at least three to six months. 
 
Pain associated with cancer includes pain associated with disease progression as well as treatments. Pain 
associated with cancer can have multiple causesnamely, disease progression, treatment (e.g., neuropathic 
pain resulting from radiation therapy), and co-occurring diseases (e.g., arthritis). Regardless of whether the pain 
associated with cancer stems from disease progression, treatment, or a co-occurring disease, it may be either 
acute or chronic. 
 
Postlaminectomy syndrome/failed back syndrome or pain following operative procedures of the spine, 
sometimes known as failed management syndrome, is becoming an increasingly common entity in modern 
medicine. Other spinal conditions causing pain include various degenerative disorders such as spinal stenosis, 
spondylolysis, spondylolisthesis, degenerative scoliosis, idiopathic vertebrogenic sclerosis, diffuse idiopathic 
spinal hyperostosis, and segmental instability. Degenerative conditions other than disc disruption and facet 
arthritis may contribute to approximately 5% to 10% of spinal 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. 
 
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 these rules 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.