Date Printed: May 24, 2018: 12:02 PM

Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

Subject: Sacroiliac Joint Injections

Member View

inical_view_eng_btn mber_view_sp_btn


This medical coverage guideline is not an authorization, certification, explanation of benefits, or a guarantee of payment, nor does it substitute for or constitute medical advice. All medical decisions are solely the responsibility of the patient and physician. Benefits are determined by the group contract, member benefit booklet, and/or individual subscriber certificate in effect at the time services were rendered. This medical coverage guideline applies to all lines of business unless otherwise noted in the program exceptions section.



Sacroiliac joint injections may help manage some types of chronic lower back pain. The sacroiliac joint occurs where two bones in the back, the ilium and the sacrum, meet. The pain may occur at the joint itself or in the nearby muscles or ligaments. Pain may also radiate to either or both hips or legs.

In a sacroiliac joint injection, your doctor inserts a long needle into the space between the bones in your lower back. Using a fluoroscope or other X-ray device, the needle is guided to the base of the irritated nerve. Your doctor then injects medicine to block the pain and reduce swelling.

After first taking your medical history and examining you, your doctor will evaluate you for treatment. Your doctor may first try other more conservative treatments to relieve your pain. These may include medication, physical therapy or chiropractic treatment. If these do not work, your doctor may then try sacroiliac joint injections.

Typically, you first receive one to two injections to see if they relieve your pain. If your pain improves, you may receive additional injections over time. Your doctor will continue to measure your improvement.

Visit the Clinical View of this guideline for more information.

Visit WebMD for more information on using sacroiliac joint injections to treat lower back pain.



Note: For all medical decisions about this service, Florida Blue uses the Position Statement in the Clinical View of this medical coverage guideline. To make the best decision for your health needs, talk to your doctor. The services covered vary from health plan to health plan. Refer to your health plan contract for complete information about your coverage.


Sacroiliac joint injections may be covered if certain requirements are met.

Visit the Clinical View of this guideline for specific coverage information.


• Federal Employee Program (FEP): Certain exceptions apply.

• State Account Organization (SAO): Certain exceptions apply.

• Medicare Advantage products: Certain exceptions apply.

Visit the Clinical View of this guideline for more coverage information.

Refer to your health plan contract for complete information about your coverage.

Date Printed: May 24, 2018: 12:02 PM