Sacroiliac Joint Injections and Procedures

Medically reasonable SIJ injections are covered only for patients with ≥3 months of moderate-to-severe low back pain localized to the sacroiliac joint region, pain below L5 without radiculopathy, at least three positive provocative maneuvers, failure of ≥4 weeks of conservative therapy, and exclusion of other lumbosacral causes. Diagnostic SIJ injections require image guidance (CT/fluoroscopy with contrast except for documented allergy/pregnancy) and ≥75% pain relief to qualify, therapeutic injections require documented ≥50% sustained pain or functional improvement for ≥3 months, diagnostic sessions are limited to 2 total and therapeutic sessions to 4 per rolling 12 months; SIJ denervation (RFA), biologic injectates, and injections without image guidance are not covered.

"Sacroiliac joint injection (SIJI) is medically reasonable and necessary when ALL of the following are met: moderate-to-severe low back pain localized to the SIJ region (between iliac crests and glu..."