Medicare Injections

Depending on the procedure codes entered for authorizations, the following documentation may be required. In very few circumstances, additional information that is not listed may be requested.

For every authorization, regardless of service, please include an office visit note with TWO (2) patient identifiers.

We encourage all users to print this checklist and utilize it when submitting the following services for Medicare members:

  • Sacroiliac joint injections (SI joint)
  • Spine facet joint injections
  • Initial & repeat spine radiofrequency ablation(RFA)
  • Epidural steroid injections (ESI)
  • Medial branch block (MBB)  



Advanced imaging

  • MRI and/or CT scan
  • Dated imaging report

SI joint provocative testing

Documentation of a minimum of 3 tests. 

  • Includes: Patrick‚Äôs or FABER, Gaenslen, thigh thrust, sacral thrust, distraction, compression

Functional impairment of Activity of daily living (ADLs)

Include numeric pain scale and any pain causing movements

Outcome of prior treatments

If applicable, the percent (%) of relief from previous injections and duration of relief

Patient information

Most recent office visit note(s) including the surgical plan/order

Conservative Therapy

Include duration and dates of therapy.

*Depending on procedure 4 weeks may be requested

  • Activity/ lifestyle modifications
  • Home exercise program

Physical Therapy

Include PT notes with duration and dates of PT


Non- steroidal anti-inflammatory drugs, Non-Narcotic Analgesics, Narcotic Analgesics, Neurogenic Pain Medication (Gabapentin, Lyrica, etc.)

Pain Duration

Include specific dates

  • ESI-4 Weeks (For most states)
  • Facet- 3 months
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