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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 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, AND 
Low back pain persists despite a minimum of four weeks of conservative therapies. 
B. Diagnostic Sacroiliac Joint Injections 
 
          Diagnostic SIJI is used to determine if the etiology of pain is from the sacroiliac joint complex. 
 
          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, 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 percent relief of primary (index) pain with the diagnostic SIJI (a 
positive diagnostic response is defined as equals 75 percent sustained and constant pain relief for the duration 
of the local anesthetic and equals 75 percent 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. 
 
You can find these rules in 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.