CMM-203: Sacroiliac Joint Injections

Diagnostic intra‑articular sacroiliac joint (SIJ) injections are covered only when pain is localized between the iliac crests and gluteal fold, other causes are excluded by imaging, at least three provocative tests reproduce pain, ≥4 weeks of conservative care plus active rehabilitation are documented, and injections are performed under fluoroscopy with contrast; therapeutic SIJ injections are allowed only after a diagnostic block yields ≥75% pain relief, with repeat therapeutics requiring documented clinical benefit (improved function or reduced medication/therapy), no more than four injections per joint per 12 months, and ≥2 months between injections. Ultrasound guidance and sacral lateral branch procedures are considered experimental/investigational, and injections without appropriate imaging guidance, performed in isolation (without active rehabilitation), or on the same day as a facet/epidural/lumbar sympathetic block 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 ALL of the following..."