What makes less sense to me is the verbiage regarding diagnostic and therapeutic SI joint injections. It almost makes it sound like you have to do an diagnostic first? What would that look like, a shot without steroid?
B. Diagnostic SIJIs
Diagnostic SIJI is used to determine if the etiology of pain is from the SIJ complex.3
Diagnostic SIJI are considered reasonable and necessary for patients who meet ALL the following criteria:
1. The patient must meet the above criteria for Covered Indications for SIJI, AND
2. The SIJI must be performed under CT or fluoroscopy image guidance with contrast, except ultrasound guidance may be considered reasonable and necessary when there is a documented contrast allergy or pregnancy, since the accuracy with ultrasound guidance is inferior to fluoroscopic guidance,6 AND
3. SIJI are not performed with other musculoskeletal injections in the lumbosacral spine, AND
4. The documentation should show direct causal benefit from the SIJI and not from other musculoskeletal injections or treatments, AND
5. The diagnostic SIJI provided a minimum of 75% relief of primary (index) pain with the diagnostic SIJI (a positive diagnostic response is defined as ≥75% sustained and constant pain relief for the duration of the local anesthetic and ≥75% sustained and constant pain relief for the duration of the anti- inflammatory steroid) was measured by the SAME pain scale* at baseline. The measurements of pain must be taken pre-injection on the day of the SIJI, post-intervention on the day of the injection, and the days following the injection to substantiate and corroborate the pain scores consistent with the pain relief for the duration of the local anesthetic and/or steroid used.
Limitation: No more than 2 diagnostic joint sessions, unilateral or bilateral. To clarify, 2 unilateral sessions, if performed on 1 side at 1 session and on the opposite side at a different session, would meet the limitation of 2 diagnostic sessions.
Therapeutic SIJI
Therapeutic SIJI will be considered medically reasonable and necessary for patients who meet ALL the
following criteria:
1. The patient must meet the above criteria of Covered Indications for SIJI, AND
2. The diagnostic SIJI provided a minimum of 75% relief of primary (index) pain with the diagnostic SIJI (a positive diagnostic response is defined as ≥75% sustained and constant pain relief for the duration of the local anesthetic and ≥75% sustained and constant pain relief for the duration of the anti- inflammatory steroid) was measured by the SAME pain scale* at baseline. The measurements of pain were taken pre-injection on the day of the diagnostic SIJI, post-intervention on the day of the diagnostic injection, and the days following the diagnostic SIJI to substantiate and corroborate consistent pain relief for the duration of the local anesthetic and/or steroid used, AND
3. Subsequent therapeutic SIJI are considered medically reasonable and necessary when the subsequent
SIJI are provided at the same anatomic site as therapeutic SIJI, AND the therapeutic SIJI produced at least consistent 50% pain relief or at least 50% consistent improvement in the ability to perform previously painful movements and activities of daily living (ADLs) for at least 3 months from the proximate therapeutic SIJI procedure and compared to baseline measurements for ADLS and painful movements or pain relief using the same pain scale* AND
4. The SIJIs must be performed under computed tomography (CT) or fluoroscopy image guidance with contrast, except ultrasound guidance may be considered reasonable and necessary when there is a documented contrast allergy or pregnancy, since the accuracy with ultrasound guidance is inferior to fluoroscopic guidance.
Limitation: No more than 4 therapeutic SIJI sessions, unilateral or bilateral, will be reimbursed per rolling 12 months. To clarify, a therapeutic SIJI session if performed on 1 side first and then on the opposite side at a different session would qualify as 2 sessions for the frequency limitation of 4 therapeutic SIJ sessions per rolling 12 months.