CMM-203: Sacroiliac Joint Injections

Covered only when strict criteria are met: diagnostic SI joint injections require ≥4 weeks of conservative therapy, ongoing active participation in a rehabilitative/exercise program, clinical evidence (pain between iliac crests and gluteal fold, imaging excluding other causes, and reproduction of pain with ≥3 provocative tests), and a positive diagnostic block (≥75% pain relief) before a therapeutic injection. Intra‑articular injections must use fluoroscopy with contrast (ultrasound is investigational), peri‑articular may be with or without fluoroscopy, therapeutic injections are limited to ≤4 per joint per 12 months and no more often than every 2 months, and procedures done without appropriate guidance, same‑day conflicting procedures, or in isolation (no rehab) are not medically necessary.

"The performance of a diagnostic sacroiliac joint injection for localized, sacroiliac joint pain resulting from disease, injury or surgery is considered medically necessary when pain persists despit..."