CMM-203: Sacroiliac Joint Procedures

Fluoroscopic- or CT‑guided intra‑articular sacroiliac (SI) joint injections with anesthetic, corticosteroid and contrast are covered when medical necessity criteria are met; ultrasound guidance, biologic injectates (e.g., PRP, stem cells, amniotic fluid), and L5 medial/sacral lateral nerve branch blocks/ablations are not covered. Coverage requires pain primarily between the iliac crests and gluteal fold, exclusion of other causes by clinical/imaging evaluation, reproduction of pain with ≥3 provocative SI tests, failure of ≥4 weeks of conservative therapy with continued rehab, documented ≥75% pain relief from a diagnostic injection to qualify for therapeutic injections, and adherence to limits (≤2 diagnostic; ≤4 therapeutic per joint per rolling 12 months with ≥2 months between therapeutics) and fluoroscopic/CT guidance with contrast.

"An initial diagnostic sacroiliac joint injection for localized sacroiliac joint pain resulting from disease, injury, or surgery is considered medically necessary when ALL of the following criteria ..."