CMM-203: Sacroiliac Joint Procedures

Covers diagnostic and therapeutic intra‑articular sacroiliac joint injections (anesthetic, corticosteroid, contrast) when pain is localized between the iliac crests and gluteal fold, imaging excludes other causes, pain is reproduced with ≥3 specified provocative tests, ≥4 weeks of conservative care with continued rehabilitation has failed, diagnostic response is ≥75% (required before therapeutic), procedures use fluoroscopic/CT guidance with contrast, and limits are up to 2 diagnostic and up to 4 therapeutic injections per joint per rolling 12 months with ≥2 months between therapeutics. Excluded/not medically necessary: ultrasound guidance, biologic or other non‑approved injectates (e.g., PRP, stem cells), and L5 medial/sacral lateral nerve branch blocks/ablations or any injections not meeting the above criteria.

"Documentation of injectates used (must be anesthetic, corticosteroid, and/or contrast agent; biologics and other injectates are excluded)."