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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 state that: 
A. 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,
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 AND 
6. Low back pain persists despite a minimum of four weeks of conservative therapies.
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B. Diagnostic Sacroiliac Joint Injections 
          Diagnostic SIJI is used to determine if the etiology of pain is from the sacroiliac joint complex.
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          Diagnostic SIJI are considered reasonable and necessary for patients who meet ALL the following 
criteria: 
1. The patient must meet the above criteria for Covered Indications for SIJI, AND 
2. 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,
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 AND 3. SI joint injection are not performed with other musculoskeletal injections in the lumbosacral 
spine, AND 
4. The documentation should show direct causal benefit from the SI joint injection and not from 
other musculoskeletal injections or treatments, AND 
5. 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: 
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 
(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 
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 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.
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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 frequency 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. 
 
 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.
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 The SIJ procedure(s) should be performed in conjunction with conservative treatments.
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 Patient should be part of an ongoing, and be actively participating in a rehabilitation program, home 
exercise program or functional restoration program.
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 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 
1. Injections performed without radiographic image guidance are not considered reasonable and 
necessary.
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2. 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. 
3. 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. 
4. 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.
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 Even in patients with a needle phobia and anxiety, typically oral anxiolytics 
suffice.
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5. 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. 
6. SIJIs used as part of a series of lumbar spine and musculoskeletal injections to treat nonspecific or 
chronic low back pain are not considered reasonable and necessary. 
7. 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. 
8. Patients with coexisting psychological conditions or depression related illness should be treated and 
stabilized prior to proceeding with interventional procedures.
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 Multidisciplinary biopsychosocial 
rehabilitation principles should be provided to these patients. 9. 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: 
a. 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. 
b. 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. 
c. 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. 
d. 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). 
10. A subsequent diagnostic SIJI is not reasonable and necessary when the initial diagnostic block does not 
produce a positive response of  75% pain reduction. 
11. 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 rule at the Medicare Local Coverage Determination (LCD) L39464: Sacroiliac Joint 
Injections and Procedures. 
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.