CMM-203: Sacroiliac Joint Injections

Covered: diagnostic (intra‑ or peri‑articular) and therapeutic SI joint injections performed with fluoroscopic guidance and contrast are medically necessary for localized SI joint pain, while ultrasound guidance or injections without fluoroscopic/alternative imaging guidance are investigational/not medically necessary (and same‑day injections with certain other spine procedures are not covered). Key requirements: ≥4 weeks of conservative therapy plus active participation in rehabilitation are required before diagnostic injection; a diagnostic block must produce ≥75% pain relief to permit therapeutic injections; repeat therapeutics require prior ≥75% relief, improved function or reduced medication, ≥2 months between injections, and no more than four injections per joint in 12 months.

"A subsequent diagnostic block is not medically necessary when the initial diagnostic block did not produce a positive response of ≥75% pain reduction."