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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 SIJIs will be considered medically reasonable and necessary when all the following 
requirements are met: 
 
  
  Moderate to severe LBP primarily experienced over the anatomical location of the SIJs between the upper level 
of the iliac crests and the gluteal fold, AND 
LBP duration of at least 3 months, AND 
LBP 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 3 positive findings with provocative maneuvers: FABER, Gaenslen, Thigh Thrust or Posterior Shear, 
SI Compression, SI Distraction and Yeoman Tests,3,4 AND 
LBP persists despite a minimum of 4 weeks of conservative therapies. 
B. Diagnostic SIJIs 
 
          Diagnostic SIJI is used to determine if the etiology of pain is from the SIJ 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 SIJIs 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,6 AND 
SIJI are not performed with other musculoskeletal injections in the lumbosacral spine, AND 
The documentation should show direct causal benefit from the SIJI 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 SIJI, 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 2 diagnostic joint sessions, unilateral or bilateral. To clarify, 2 unilateral sessions, if 
performed on 1 side at 1 session and on the opposite side at a different session, would meet the limitation of 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 SIJI, post-intervention on the day of the diagnostic injection, and the days following the 
diagnostic SIJI 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 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 SIJIs 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 
Limitation: No more than 4 therapeutic SIJI sessions, unilateral or bilateral, will be reimbursed per rolling 12 
months. To clarify, a therapeutic SIJI session if performed on 1 side first and then on the opposite side at a 
different session would qualify as 2 sessions for the limitation of 4 therapeutic SIJ sessions per rolling 12 
months. 
 
You can find this information in the Local Coverage Determination (LCD) Sacroiliac Joint Injections and 
Procedures L39402. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.