Sacroiliac Joint Injections and Procedures

Sacroiliac joint injections are medically reasonable when patients have chronic (≥3 months) moderate-to-severe low back pain localized to the SIJ region, pain below L5 without radiculopathy, at least three positive provocative maneuvers, and failure of ≥4 weeks of conservative therapy. Diagnostic blocks must be image-guided (CT/fluoroscopy with contrast; ultrasound only for contrast allergy/pregnancy) and show ≥75% pain relief to justify therapeutic injections, which are limited to 4 sessions per rolling 12 months (diagnostic blocks limited to 2 sessions); SIJ denervation (RFA), biologic injectates, injections without imaging guidance, and injections for non-specific or non-SIJ pain are not covered.

"Moderate to severe low back pain primarily located over the sacroiliac joints between the iliac crests and the gluteal fold."

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