Authorization for Sacroiliac (SI) joint injections
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This document governs prior authorization submission requirements for sacroiliac (SI) joint injections for HealthPartners members and describes information providers must supply when requesting authorization.
No material clinical or coverage changes in this revision.
Coverage Criteria for SI Joint Injections
General medical necessity and documentation
Coverage contingent on submitted documentation and frequency limits.
PT documentation required if conservative therapy criterion met
Diagnostic injections
Diagnostic injection rules.
Therapeutic injections
Therapeutic injection limits.
Submit prior injection dates and relief details
Conservative treatment
Conservative therapy preference.
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
| Primary diagnosis code | Description |
| Secondary diagnosis code | Description |
| Procedure code(s) | Only include codes requiring authorization; other codes will not be addressed |
Provider Submission & Documentation Requirements
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.
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.
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.
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
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.
Attach PT notes to the authorization request
Frequency Limits
Imaging / Procedural Details
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.
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