The policy requires a period of four weeks of conservative therapy before proceeding with intervention. The patient should be informed that it is expected and required for coverage that aspects of conservative therapy determined to be most beneficial for the patient will be continued in conjunction with SIJIs as part of the treatment program. The patient and provider can determine the choice of conservative treatments and document this in the medical record.

Conservative treatment is defined in the policy as an appropriate combination of medication (for example, NSAIDs, analgesics, etc.) in addition to physical therapy, spinal manipulation therapy, CBT, home exercise program, or other interventions based on the individual’s specific presentation, physical findings and imaging results.