Sacroiliac Joint Injections and Procedures

Sacroiliac joint injections are covered when patients have at least 3 months of low back pain localized to the SIJ (between the iliac crests and gluteal fold), 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 must be image-guided (CT/fluoroscopy with contrast; ultrasound only for contrast allergy or pregnancy) and produce ≥75% pain relief to qualify for subsequent therapeutic injections, which must provide ≥50% pain or functional improvement for ≥3 months; diagnostic sessions are limited to 2 and therapeutic sessions to 4 per rolling 12 months, and SIJ denervation (RFA), biologic injectates, injections without image guidance, and SIJIs for specified non-SIJ diagnoses are not covered.

"Low back pain primarily located over the anatomical SI joints between the upper level of the iliac crests and the gluteal fold."