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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: 
 
    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: FABER, Gaenslen, Thigh Thrust or Posterior 
Shear, SI Compression, SI Distraction and Yeoman Tests,3,4 AND 
    Low back pain persists despite a minimum of four weeks of conservative therapies.5 
 
B. Diagnostic Sacroiliac Joint Injections 
 
Diagnostic SIJI is used to determine if the etiology of pain is from the sacroiliac joint complex.3 
 
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 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,6 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. 
 
C. Therapeutic SIJI: 
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 =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 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 
    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 
    The SI joint injections 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,6 
 
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. 
 
D. SIJ Denervation (also called Radiofrequency Ablation or RFA) is not considered reasonable and necessary. 
 
*Note: The scales used to measure of pain and/or disability must be documented in the medical record. 
Acceptable scales include but are not limited to: verbal rating scales, Numerical Rating Scale (NRS) and Visual 
Analog Scale (VAS) for pain assessment, and Pain Disability Assessment Scale (PDAS), Oswestry Disability 
Index (ODI), Oswestry Low Back Pain Disability Questionnaire (OSW), Quebec Back Pain Disability Scale 
(QUE), Roland Morris Pain Scale, Back Pain Functional Scale (BPFS), and the PROMIS profile domains to 
assess function. 
 
E. Requirements 
 
    The SIJI must be performed under CT or fluoroscopy image guidance with contrast, unless the patient has a 
documented contrast allergy or pregnancy where ultrasound guidance without contrast may be considered.6 
    The SIJ procedure(s) should be performed in conjunction with conservative treatments.7     Patient should be part of an ongoing, and be actively participating in a rehabilitation program, home exercise 
program or functional restoration program.8,9 
    SIJ primary index pain must be measured prior to the injection at the beginning of the session. 
    The post procedure pain level must be measured after the SIJ injection at the conclusion of the session. 
    SIJI may be performed unilateral or bilateral if clinically indicated within the same session. 
    The documentation must have the radiographic films (i.e. fluoroscopy images) of the procedure in at least 
two (2) views (i.e., the pre and post contrast injection views in the AP and oblique planes) to confirm 
intraarticular injection of contrast and the treatment agent(s) used. 
    When documenting the percentage of pain relief from the primary (index) pain compared to the post-
injection pain levels, it is insufficient to report only a percentage of pain relief and/or a nonspecific statement of 
the duration of pain relief. The documentation should include a specific assessment of the duration of relief 
being consistent or inconsistent with the agent used for the injection and the specific dates the measurements 
were obtained using the SAME pain scale* used at baseline. 
    When documenting the ability to perform previously painful movements and activities of daily living 
(ADLs) it is insufficient to provide a vague or nonspecific statement regarding the improvement of previously 
painful movements and activities of daily living (ADLs). The documentation should include a functional 
assessment to show clinically meaningful improvement with painful movements and ADLs, if this metric is 
used to justify the efficacy of the SIJI procedure. Providers should use established and measurable goals and 
objective scales to assess functionality and ADLs measures. 
 
Limitations 
 
    Injections performed without radiographic image guidance are not considered reasonable and necessary.6 
    A SIJI involves the use of an anesthetic, corticosteroid, and contrast agent and does not include injections of 
biologics (e.g., platelet rich plasma, stem cells, amniotic fluid, etc.) and/or any other injectates. 
    It is not considered medically reasonable and necessary to perform multiple blocks (ESI, sympathetic blocks, 
facet blocks, trigger point injections, etc.) during the same session as SIJs injections and during the post SIJ 
injection efficacy assessment period. 
    Use of Moderate or Deep Sedation, General Anesthesia, and Monitored Anesthesia Care (MAC) is usually 
unnecessary or rarely indicated for SIJ injections and therefore not considered medically reasonable and 
necessary.10 Even in patients with a needle phobia and anxiety, typically oral anxiolytics suffice.9 
    SIJIs to treat non-specific low back pain (LBP), axial spine pain primary above the level of L5, complex 
regional pain syndrome, widespread diffuse pain, chronic pain syndrome, and pain from neuropathy are 
considered investigational and therefore are not considered medically reasonable and necessary. 
    SIJIs used as part of a series of lumbar spine and musculoskeletal injections to treat nonspecific or chronic 
low back pain is not considered reasonable and necessary. 
    In patients with implanted electrical devices, (i.e., spinal cord stimulation, peripheral nerve stimulation, 
cardiac devices, etc.) and intrathecal pump delivery devices, providers should follow manufacturer instructions 
and extra planning as indicated to ensure safety of the procedure. 
    Patients with coexisting psychological conditions or depression related illness should be treated and 
stabilized prior to proceeding with interventional procedures.11 Multidisciplinary biopsychosocial 
rehabilitation principles should be provided to these patients. 
    It generally would not be considered medically reasonable and necessary for treatment with SIJIs to extend 
beyond 12 months. Frequent continuation of SIJIs injections over 12 months may trigger a focused medical 
review. Use beyond twelve month requires the following: 
        Pain is severe enough to cause a significant degree of functional disability or vocational disability and 
providers use established and measurable goals and objective scales to assess functionality and ADLs 
measures. 
        SIJIs provides at least 50% sustained and consistent improvement of pain and/or 50% sustained and 
consistent objective improvement in function (using same scale as baseline) for at least three (3) months. 
        Rationale for the continuation of SIJIs including but not limited to patient who are high-risk surgical 
candidates, the patient does not desire surgery, and/or the recurrence of pain in the same location was sustained and consistently relieved with the SIJIs for at least three (3) months. 
        The primary care provider should be notified regarding continuation of procedures and prolonged repeat 
steroid use to allow for systematic care delivery treatment surveillance and multidisciplinary biopsychosocial 
rehabilitation (MBR). 
    A subsequent diagnostic SIJI is not reasonable and necessary when the initial diagnostic block does not 
produce a positive response of = 75% pain reduction. 
    A subsequent therapeutic SIJI is not reasonable and necessary when the proximate SIJI did not provide at 
least a consistent 50% pain relief or at least a 50% consistent improvement in the ability to perform previously 
painful movements and activities of daily living (ADLs) for at least three (3) months compared to baseline 
objective measurements for ADLS and painful movements or pain relief using the same pain scale* 
 
You can find this information in the Local Coverage Determination (LCD) Sacroiliac Joint Injections and 
Procedures L39475. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.