CurrentHealthPartnersPolicy 20-913603-913616

Authorization for Sacroiliac (SI) joint injections

This document governs prior authorization submission requirements for sacroiliac (SI) joint injections for HealthPartners members and describes information providers must supply when requesting authorization.

Policy Summary

PayerHealthPartners

PolicyAuthorization for Sacroiliac (SI) joint injections

Policy CodePolicy 20-913603-913616

Change TypeNo material clinical or coverage changes

Effective Date

Next Review Date

Key ActionSubmit a prior authorization request via the HealthPartners Provider Portal (or fax for specified commercial products) with completed authorization form and supporting clinical documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4Therapeutic limit (12 mo)

12 moRepeat diagnostic window

4 visitsPT visits required

952-853-8713Commercial fax

Coverage Criteria for SI Joint Injections

General medical necessity and documentation

Coverage contingent on submitted documentation and frequency limits.

Authorization prerequisites: Provider must submit clinical documentation supporting medical necessity including severity, location, duration of pain, and conservative treatment attempts; complete prior authorization form with primary and secondary diagnosis codes and proposed procedure code(s) and units; indicate whether injection is diagnostic or therapeutic and provide prior injection dates and percentage/duration of relief for prior injections.

PT documentation required if conservative therapy criterion met

Diagnostic injections

Diagnostic injection rules.

Diagnostic injection repetition: A diagnostic injection completed within 12 months of the previous diagnostic SI injection will be considered a repeat injection and may be authorized as a repeat; if longer than 12 months have lapsed since the previous diagnostic injection, criteria for an initial SI injection must be met.

Policy Summary

PayerHealthPartners

PolicyAuthorization for Sacroiliac (SI) joint injections

Policy CodePolicy 20-913603-913616

Change TypeNo material clinical or coverage changes

Effective Date

Next Review Date

SourceLink

On This Page

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Therapeutic injections

Therapeutic injection limits.

Therapeutic injections frequency: A maximum of 4 therapeutic SI injections in a 12‑month period are allowed. Providers must check and date injections already received and submit clinical documentation indicating pain relief from previous injections, including percentage and duration of relief.4 per 12 months

Submit prior injection dates and relief details

Conservative treatment

Conservative therapy preference.

Physical therapy requirement: Indicate whether the member completed at least 4 physical therapy visits over a course of 6 weeks or less within the last 6 months for the current episode of pain; if yes, submit PT notes.4 visits in 6 weeks

Applies to current episode within last 6 months

Only procedure codes that require prior authorization are addressed on this form. Other procedure codes, including those not listed as authorization-required, will not be considered via this document and should not be submitted on this authorization request.

Authorization and Procedure Codes

Authorization form fields / codesmixed

Primary diagnosis code	Description
Secondary diagnosis code	Description
Procedure code(s)	Only include codes requiring authorization; other codes will not be addressed

inv-07: Therapeutic injection frequency — Maximum of 4 therapeutic injections per 12 months

Therapeutic injection frequencyMaximum of 4 therapeutic injections allowed per 12-month period.

Documentation requiredCheck and date injections already received (first, second, third, fourth) and submit clinical documentation indicating pain relief from previous injections.

Pain relief detailsReport whether prior injection provided relief, percentage of pain relief, and duration of relief.

Provider Submission & Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization submission — Prior authorization is required for SI injection procedure codes listed on the form. For commercial Sl products, fax completed forms to HealthPartners at (952) 853-8713 or submit via the HealthPartners Provider Portal. For Medicare Advantage, MSHO, Medicaid and commercial Fl products, submit PA requests to Cohere through the HealthPartners Provider Portal (register at coherehealth.com/register). Use the Authorizations and Referrals link in the Provider Portal to check status. Call Utilization Management (UM) at (952) 883-6333 with questions.

Only include codes requiring authorization; other codes will not be addressed.
Submit clinical documentation to support the request; incomplete forms will be returned or may lead to denial.
If submitting to Cohere, register at coherehealth.com/register and submit via the HealthPartners Provider Portal.

Documentation Required

Conservative Therapy Required

Conservative therapy documentation — Providers must document that the member has completed at least 4 physical therapy visits over a course of 6 weeks or less within the last 6 months for the current episode of pain. If yes, PT notes must be submitted with the authorization request.

Has the member completed ≥4 PT visits over ≤6 weeks within the last 6 months for the current episode? (Yes/No)
If yes, attach PT notes documenting dates, treatments, and response.

Documentation Required

Required Clinical Documentation

Required clinical documentation — Submit clinical documentation that supports medical necessity including severity, location, and duration of pain; conservative treatment attempts; prior injection dates and outcomes; and whether the injection is diagnostic or therapeutic. For therapeutic injections, document prior injections and pain relief; a maximum of 4 therapeutic injections in a 12‑month period is allowed. For diagnostic injections, a repeat diagnostic injection within 12 months of a prior diagnostic injection is considered a repeat; if >12 months have elapsed, criteria for an initial injection must be met.

Clinical details: severity, location, duration of pain, and conservative treatments attempted.
Injection intent: Therapeutic or Diagnostic.
If repeat therapeutic injections: list dates of prior injections (up to 4 in 12 months) and documentation of pain relief and duration.
If repeat diagnostic injection within 12 months, note prior diagnostic injection date; if >12 months, meet initial injection criteria.

Denial Risk

Documentation Completeness

Documentation completeness — Incomplete forms or missing supporting clinical documentation will be returned or may lead to denial. Only codes that require authorization will be addressed in the request; include primary and secondary diagnosis codes, procedure code(s), proposed date, units, and a clinical reason for urgency if applicable.

Include: primary and secondary diagnosis codes and descriptions, procedure code(s) and units, proposed procedure date (or TBD).
Explain urgency: will waiting the standard review time seriously jeopardize the member's health, life, or ability to regain maximum functioning? Provide clinical reason for urgency (not scheduling issues).
Incomplete or missing PT notes, prior injection documentation, or other requested clinical records may result in return of the request or denial.

Background

This policy governs prior authorization for sacroiliac (SI) joint injections used to evaluate or treat SI joint pain and differentiates between diagnostic and therapeutic injections. Providers must indicate whether the requested injection is diagnostic or therapeutic, and the form requests prior injection dates and the percentage and duration of any pain relief from prior injections.

For diagnostic injections, a diagnostic injection completed within 12 months of a prior diagnostic SI injection is considered a repeat diagnostic injection; if more than 12 months have elapsed since the prior diagnostic injection, the criteria for an initial SI injection apply.

For therapeutic injections, the policy limits frequency and requires documentation of prior response: a maximum of 4 therapeutic injections in a 12‑month period are allowed. The form asks providers to list dates of prior therapeutic injections and to document whether prior injections provided relief, including the percentage and duration of relief.

Definitions

inv-13: Repeat diagnostic injection — A diagnostic injection completed within 12 months of the previous diagnostic SI injection is considered a repeat injection; if >12 months...

Definition of repeat diagnostic injectionA diagnostic injection completed within 12 months of the previous diagnostic SI injection is considered a repeat injection.

If >12 months elapseIf longer than 12 months have lapsed since the previous diagnostic injection, criteria for an initial SI injection must be met.

Form selectionWhen requesting authorization, indicate whether the injection is diagnostic and select initial vs repeat injection (right/left).

inv-14: Therapeutic injection limit — A maximum of 4 therapeutic injections in a 12 month period are allowed; documentation of prior injection dates and pain relief must be su...

Therapeutic injection limitA maximum of 4 therapeutic injections in a 12-month period are allowed.

Prior injection reportingProviders must check and date injections already received on the form (first through fourth injection dates).

Evidence of benefitSubmit clinical documentation indicating whether the previous injection provided relief, the percent of pain relief, and duration of relief.

Supporting documentationInclude severity, location, duration of pain, conservative treatment attempts, and PT notes if applicable.

Conservative Treatment Requirements

4 PT visits — documentation of at least 4 physical therapy visits over 6 weeks

Document at least 4 physical therapy visits over a course of 6 weeks or less within the last 6 months for the current episode of pain; submit PT notes if completed.

PT visits documented: At least 4 physical therapy visits completed within a course of 6 weeks or less for the current episode of pain, occurring within the last 6 months must be documented in submitted records.>=4 visits within 6 weeks

Attach PT notes to the authorization request

Frequency Limits

inv-16: Therapeutic SI joint injections — Maximum of 4 therapeutic injections

Maximum allowedMaximum of 4 therapeutic SI joint injections per 12 months.

Record keepingDocument dates of prior therapeutic injections on the authorization form (first, second, third, fourth).

Prior relief documentationIndicate if previous injections provided relief and specify percent and duration of relief.

Imaging / Procedural Details

Note

Indicate diagnostic vs therapeutic and prior injection response

The form asks whether the injection is diagnostic or therapeutic and for prior injection response (dates, whether prior injections provided relief, percentage and duration of relief); include these details when submitting the authorization request.

Indicate Therapeutic or Diagnostic on the form
List dates of prior injections and whether they provided relief
State percentage and duration of prior pain relief

Not Covered

Procedure codes that do not require prior authorization are not covered by this authorization form and are not addressed by this document. Do not submit requests for procedure codes that are not listed as requiring authorization on the form; such codes will not be reviewed through this process.