Sacroiliac Joint Injections and Procedures

SIJ injections are covered when patients have chronic (≥3 months) moderate-to-severe low back pain localized to the sacroiliac joint below L5 without radiculopathy, have failed conservative therapy, demonstrate ≥3 positive SIJ provocative tests, and meet imaging and documentation requirements. Diagnostic SIJIs require CT/fluoroscopic guidance with contrast (ultrasound only for contrast allergy or pregnancy) and ≥75% diagnostic pain relief to qualify; therapeutic SIJIs require documented ≥50% sustained pain or function improvement for ≥3 months to continue, with limits of ≤2 diagnostic sessions and ≤4 therapeutic sessions per rolling 12 months; RFA and nonstandard injectates are excluded.

"Sacroiliac joint injection (SIJI) may be considered when patient has moderate to severe low back pain primarily localized over the SI joints between the iliac crests and the gluteal fold."