CMM-203: Sacroiliac Joint Procedures

Fluoroscopy- or CT-guided intra‑articular sacroiliac joint injections using anesthetic and/or corticosteroid with contrast are covered when criteria are met; ultrasound guidance, biologic injectates (e.g., PRP, stem cells, amniotic fluid) and L5 medial/sacral lateral nerve branch procedures are experimental/investigational and not covered. Coverage requires documented pain primarily between the iliac crests and gluteal fold with other causes excluded by exam/imaging, reproduction of pain with ≥3 provocative tests, ≥4 weeks of conservative therapy, a diagnostic injection showing ≥75% pain relief (up to two diagnostics) before therapeutics, and limits of ≥2 months between therapeutic injections and no more than four therapeutic injections per joint in any rolling 12‑month period with documented prior therapeutic benefit (≥75% pain reduction for ≥2 weeks plus functional improvement or reduced medication/service use) for repeats.

"Diagnostic sacroiliac joint injection for localized sacroiliac joint pain resulting from disease, injury, or surgery when ALL of the following criteria are met: (a) Pain primarily experienced betwe..."