CMM-203: Sacroiliac Joint Injections

Covered: sacroiliac (SI) joint injections are medically necessary for localized SI joint pain after ≥4 weeks of failed conservative therapy; peri‑articular injections (with or without fluoroscopy) and intra‑articular injections (only fluoroscopy‑guided with contrast unless allergic) are covered, while ultrasound guidance is investigational and injections same‑day as facet/epidural/sympathetic blocks or performed without active rehabilitation are excluded. Key requirements: diagnostic blocks must produce ≥50% pain reduction during the anesthetic to be positive (no second diagnostic block if first is negative); therapeutic injections are limited to once every 2 months and ≤4/year with documented ≥50% pain relief or functional improvement for ≥4 weeks to justify repeat injections, and documentation must show pain location, negative neuro exam, ≥1 positive provocative test, prior conservative care, and fluoroscopy/contrast use or allergy.

"The performance of sacroiliac joint injections is considered medically necessary for localized sacroiliac joint pain resulting from disease, injury or surgery which has not responded sufficiently t..."