A new Department of Health and Human Services (HHS) Office of Inspector General (OIG) audit puts sacroiliac (SI) joint injections squarely in the Medicare compliance spotlight. Issued on August 3, 2026, the full OIG audit details documentation, billing, and workflow vulnerabilities that organizations performing these procedures should evaluate now. A summary of findings is also available in the OIG’s report highlights.

The audit focused on Medicare Part B physician claims for CPT 27096 (injection directly into the SI joint) and CPT 64451 (injection targeting the nerves that innervate the SI joint).

HCPCS G0260, used for the facility component of SI joint injections in applicable settings, was not included in the OIG’s physician-claim sample. ASC facility expenses were excluded from the sampling frame.

Centers for Medicare & Medicaid Services (CMS)

Medicare does not have a national coverage policy governing SI joint injections. Instead, five of the seven Medicare Administrative Contractors (MACs) have established local coverage determinations (LCDs) and related billing articles that define coverage and documentation requirements, including limits on therapeutic SI joint injections.

Because these requirements are jurisdiction-specific, organizations should evaluate SI joint injection compliance against the policy applicable to the MAC where the service is rendered.

Medicare Administrative Contractors (MACs)

For the five MACs with applicable SI joint injection policies, OIG evaluated sampled claims and supporting documentation against the relevant LCD coverage requirements and billing guidance. Organizations conducting their own reviews should likewise use the current policy applicable to their MAC jurisdiction.

The OIG Audit

The results were significant: 72% of sampled sessions failed to comply with one or more Medicare requirements. Based on those results, the OIG estimated Medicare improperly paid $15.2 million for 134,526 SI joint injections during the October 2023 – September 2024 audit period.

Separately, 25% of the sampled sessions did not meet Medicare billing guidance because they were reported as therapeutic injections when they should have been reported as diagnostic injections.

Primary Noncompliance Areas

The audit identified four primary areas of noncompliance.

• Coverage and documentation requirements
• Pain scores and imaging
• Diagnostic vs therapeutic injections
• Coverage limitations

Coverage and Documentation Requirements

Medicare LCDs require documentation supporting specific coverage criteria. Common deficiencies identified by OIG included failure to document:

• At least three positive provocative maneuvers
• Pain below L5 without radiculopathy
• At least four weeks of conservative therapy with persistent low back pain
• Chronic low back pain lasting at least three months
• Moderate to severe low back pain over the SI joints

LCDs also require no clinical findings or imaging suggesting another cause of pain. OIG identified paid SI joint injections where the documentation or imaging indicated an alternative diagnosis or cause.

Pain Scores and Imaging

Medicare LCDs require documentation of pain levels before and after SI joint injections. OIG found that more than half of the sessions reviewed lacked required pre- and/or post-procedure pain scores.

LCDs also require SI joint injections to be performed under CT or fluoroscopic guidance with contrast, except when a contrast allergy is documented. OIG identified sessions performed without contrast that lacked documentation of a contrast allergy.

Diagnostic vs. Therapeutic Injections

Medicare LCDs require documented response to prior injections before subsequent SI joint injections:

• Diagnostic: A prior diagnostic injection must provide at least 75% pain relief.
• Therapeutic: A prior diagnostic injection must provide at least 75% pain relief, and a prior therapeutic injection must result in at least 50% pain relief or three months of at least 50% functional improvement.

OIG identified sessions where these requirements were not met, including cases with no prior diagnostic injection or insufficient documented response to prior diagnostic or therapeutic injections.

Documentation should clearly identify whether the injection is diagnostic or therapeutic to support accurate classification and billing.

Coverage Limitations

Medicare LCDs generally do not consider SI joint injections medically necessary when performed during the same session as other musculoskeletal injections in the lumbosacral spine or multiple procedures, such as epidural steroid, facet-joint, or trigger point injections. OIG identified noncompliant sessions involving both circumstances.

OIG Recommendations

OIG recommended that CMS work with the MACs to:

• Develop education on Medicare billing and coverage requirements for SI joint injections.
• Develop solutions to prevent diagnostic injections from being incorrectly billed as therapeutic.
• Develop a National Coverage Determination (NCD) or encourage the two MACs without an LCD or LCA to establish policies for SI joint injections.

CMS agreed with the education-related recommendations and plans to notify the MACs of the audit, with MACs responsible for provider education. CMS did not agree with the recommendation to pursue an NCD or additional local policies, stating that education better addresses the underlying compliance issues and that individual MACs retain authority to develop LCDs.

Takeaway: Expect increased provider education and attention to SI joint injection billing and documentation requirements.

What Organizations Should Review Now

This audit supports a proactive compliance workflow:

• Before the procedure: Confirm required pain characteristics, provocative tests, conservative treatment, and other coverage criteria are documented.
• At the procedure: Document pre- and post-procedure pain scores, imaging guidance, contrast use, and other required details.
• Before billing: Verify diagnostic versus therapeutic status, modifiers, prior injection response, frequency limits, and same-session services.

Most importantly, verify the patient’s MAC jurisdiction and current policy. During OIG’s audit period, five MACs had SI joint injection LCDs and related billing articles, while First Coast and Novitas did not. Requirements may vary by jurisdiction.

Haugen Takeaway

The biggest lesson from this audit isn’t simply the $15.2 million in estimated improper payments. It’s that many deficiencies involved documentation, classification, and workflow requirements that organizations can address proactively.

SI joint injection compliance spans the entire revenue cycle, from clinical documentation and scheduling through coding and final claim review. Even when the procedure code itself is correct, insufficient documentation or failure to meet applicable coverage requirements can still result in an improper Medicare payment.

Could your SI joint injection claims withstand the same level of review? A focused internal audit can identify documentation, coding, billing, and utilization vulnerabilities before they become repayment or compliance concerns.

Schedule an internal audit of spinal pain management procedures with The Haugen Consulting Group at https://www.thehaugengroup.com/connect/.