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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 Sacroiliac joint injections (SIJI) will be considered medically reasonable and necessary 
when all the following requirements are met: 
 
1. 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 
2. Low back pain duration of at least three (3) months, AND 
3. Low back pain below L5 without radiculopathy, AND 
4. 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 
5. At least three positive findings with provocative maneuvers: FABER, Gaenslen, Thigh Thrust or Posterior  
    Shear, SI Compression, SI Distraction and Yeoman Tests, AND 
6. Low back pain persists despite a minimum of four weeks of conservative therapies. 
   
Therapeutic SIJI will be considered medically reasonable and necessary for patients who meet ALL the 
following criteria: 
 
1. The patient must meet the above criteria of Covered Indications for SIJI, AND 
2. The diagnostic SIJI provided a minimum of 75% relief of primary (index) pain with the diagnostic SIJI  
    positive diagnostic response is defined as equal to 75% sustained and constant pain relief for the duration of  
    the local anesthetic and equal to75% 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 SIJ injection, post-intervention on the day of the diagnostic  
    injection, and the days following the diagnostic SIJ injection to substantiate and corroborate consistent pain  
    relief for the duration of the local anesthetic and/or steroid used, AND 
 
 
 3. 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 three (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 
4. 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. 
 
Limitations: No more than four (4) therapeutic SIJI sessions, unilateral or bilateral, will be reimbursed per 
rolling 12 months. To clarify, a therapeutic SIJI session if performed on one side first and then on the opposite 
side at a different session would qualify as two (2) sessions for the limitation of four (4) therapeutic SIJ 
sessions per rolling 12 months. 
 
You can find this information 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.