Sacroiliac Joint Injections and Procedures
L39455
Sacroiliac joint injections are covered when patients have moderate-to-severe SIJ-localized low back pain below L5 for ≥3 months, at least three positive SIJ provocative tests, failure of ≥4 weeks of conservative therapy, and imaging/clinical evaluation excludes other causes. Diagnostic SIJIs require CT/fluoroscopic guidance with contrast (ultrasound only for contrast allergy or pregnancy) and must produce ≥75% relief to justify therapeutic injections; therapeutic SIJIs require ≥50% sustained pain or functional improvement for ≥3 months. Coverage limits include a maximum of two diagnostic sessions and four therapeutic sessions per rolling 12 months; SIJ radiofrequency ablation, biologic injectates, injections without imaging guidance, and SIJIs for non-specific or above-L5 axial pain are not covered.
"Moderate to severe low back pain primarily localized over the sacroiliac joints (between the upper iliac crests and the gluteal fold)."