Sacroiliac Joint Injections

This policy covers image-guided sacroiliac joint (SIJ) injections — including diagnostic local anesthetic SIJ or lateral/medial branch blocks using dual/controlled blocks or placebo-controlled series and image-guided therapeutic corticosteroid injections — for evaluation and treatment of suspected SIJ‑mediated low back pain. Coverage requires imaging guidance, diagnostic blocks use local anesthetic only with confirmation by two separate positive controlled blocks or an appropriate placebo-controlled series (substantial pain relief generally expected, often 75%–100%), therapeutic steroid injections require ≥3 months of failed conservative care, and limits/documentation rules apply (e.g., typically no more than three injections per 12 months).

"Injection of anesthetic for diagnostic evaluation of sacroiliac joint pain when all specified clinical criteria are met"