CMM-203: Sacroiliac Joint Procedures

Diagnostic intra‑articular SI joint injections are covered when pain is primarily between the iliac crests and gluteal fold, imaging excludes other causes, ≥3 provocative SI tests reproduce the pain, the patient has failed ≥4 weeks of conservative care and is actively participating in rehabilitation, and a diagnostic block yields ≥75% pain relief; therapeutic injections require a prior ≥75% diagnostic response and repeat therapeutic injections require ≥75% relief for ≥2 weeks plus functional improvement or reduced medication/use. Intra‑articular injections must use fluoroscopy with contrast, repeat therapeutics are limited to four per joint per 12 months with ≥2 months between injections, and ultrasound guidance, biologic injectates (e.g., PRP, stem cells, amniotic), L5/sacral lateral branch procedures, same‑day other injections, or injections performed without active rehabilitation are considered not medically necessary or experimental.

"Intra-articular sacroiliac joint injections should be performed using fluoroscopy with injection of contrast (absent allergy to contrast), as it is considered the standard of care."