CMM-203: Sacroiliac Joint Procedures

Diagnostic SI joint injections are covered only when pain is localized between the iliac crests and gluteal fold, other causes are excluded, at least three specified provocative tests reproduce the pain, and ≥4 weeks of conservative therapy with active participation in rehabilitation have failed; therapeutic injections are covered only after a diagnostic block showing ≥75% pain relief, with repeats requiring ≥75% relief from the prior therapeutic injection plus documented functional or medication-use improvement and a ≥2‑month interval. Intra‑articular injections must use fluoroscopy with contrast (unless allergic), injectates are limited to anesthetic/corticosteroid/contrast (biologics excluded), ultrasound guidance and sacral lateral branch procedures are considered experimental, same‑day spine blocks are disallowed, and frequency is limited to ≤1 injection per joint <2 months apart and ≤4 injections per joint per 12 months.

"Pain primarily experienced between the upper level of the iliac crests and the gluteal fold (the pain can refer distally, even below the knee)."