The presence of pain over the sacroiliac joint in the absence of radicular findings in and of itself does not substantiate the diagnosis of sacroiliac joint pain. There must also be clinical evidence as described below.

Intra-articular sacroiliac joint injection refers to the injection of contrast (absent allergy to contrast), followed by the introduction of a corticosteroid and/or a local anesthetic into the sacroiliac joint under fluoroscopic guidance.

Peri-articular injection refers to the introduction of a corticosteroid and/or a local anesthetic to one or more sections of the posterior ligamentous structures of the sacroiliac joint.

Sacroiliac joint pain is defined as pain originating from the sacroiliac joint and/or its supporting ligamentous structures as a result of injury, disease or surgery. Clinical components required to support the diagnosis of sacroiliac joint pain include all of the following:

• Pain primarily experienced between the upper level of the iliac crests and the gluteal fold (the pain can refer distally, even below the knee)
• Clinical findings and imaging studies suggest no other obvious cause of the pain (e.g., central spinal stenosis with neurogenic claudication/myelopathy, foraminal stenosis or disc herniation with concordant radicular pain/radiculopathy, infection, tumor, fracture, pseudoarthrosis, pain related to spinal instrumentation).
• Reproduction of pain using at least three (3) of the following provocative tests:
  • Distraction or “Gapping” or FABER/Patrick’s Test
  • Thigh Thrust or Posterior Pelvic Pain Provocational Test
  • Gaenslan’s Test
  • Sacroiliac Joint Compression Test
  • Sacral Thrust or Yeoman’s Test. 

The performance of a diagnostic sacroiliac joint injection for localized, sacroiliac joint pain resulting from disease, injury or surgery may be considered medically necessary when pain persists despite BOTH of the following:

·         A minimum of four (4) weeks of noninvasive conservative therapy (e.g., exercise, physical therapy, chiropractic care, nonsteroidal anti-inflammatory drugs [NSAIDs] and analgesics).

·         Ongoing, active participation in rehabilitative/therapeutic exercise program

A therapeutic sacroiliac joint injection for the treatment of sacroiliac joint pain may be considered medically necessary following a diagnostic injection with ≥ 75% reduction in the reported pain.

A repeat therapeutic sacroiliac joint injection for the treatment of sacroiliac joint pain may be considered medically necessary following a therapeutic injection with ≥ 75% reduction in the reported pain and BOTH of the following are met:

·         EITHER of the following:

o    Increase in the individual’s level of function (i.e., return to work); or

o    Reduction in the use of pain medication and/or additional medical services such as physical therapy/chiropractic care;

and

·         A minimum of two months since the prior injection.

Ultrasound guidance for a sacroiliac joint injection, for any indication, is considered experimental, investigational, or unproven.

A sacroiliac joint injection is considered not medically necessary for ANY of the following:

·         Sacroiliac joint injections performed without fluoroscopic or other alternative guidance, with the exception of ultrasound as noted above; or

·         When performed on the same of service as a facet joint block, epidural steroid injection, or lumbar sympathetic chain block; or

·         When performed in isolation (i.e., without the individual participating in an active rehabilitation program, home exercise program, or functional restoration program); or

·         As a subsequent diagnostic block when the initial diagnostic block does not produce a positive response of ≥ 75% pain reduction.