CMM-203: Sacroiliac Joint Procedures

Covered: diagnostic SI joint injections (anesthetic only) and therapeutic intra‑articular injections (anesthetic ± corticosteroid) are medically necessary; ultrasound guidance, sacral lateral branch neurotomies, non‑fluoroscopic/non‑contrast injections, biologic/non‑covered injectates, same‑day facet/epidural/sympathetic blocks, and injections performed without active rehabilitation are considered not medically necessary. Key requirements: pain localized between the iliac crests and gluteal fold with other causes excluded, reproduction with ≥3 provocative tests, ≥4 weeks of conservative therapy plus active rehab, diagnostic fluoroscopy‑guided (with contrast unless allergic) block showing ≥75% pain relief to qualify for therapeutic injections (max four injections per joint per 12 months, ≥2 months apart; repeats require prior ≥75% response plus improved function or reduced medication/use of services).

"A sacroiliac joint injection is considered not medically necessary when performed in isolation (i."