This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Trigger point injections (TPI) with a local anesthetic with or without steroid may be considered medically necessary when ALL of the following general and specific criteria are met:

General criteria

• There is a regional pain complaint; and
• A neurological, orthopedic or musculoskeletal system evaluation ,which includes the member's description of pain as it relates to location, quality, severity, duration, timing, context, and modifying factors, followed by a physical examination of associated signs and symptoms; and
• Conservative therapy (for example, physical or chiropractic therapy, oral analgesia, steroids, relaxants or activity modification) fails or is not feasible; and
• When necessary to facilitate mobilization and return to activities of daily living, an aggressive regimen of physical therapy or other therapeutic modalities; and
• The response to therapy must be documented for medical review prior to additional therapy authorizations.

Specific criteria

• Pain complaint or altered sensation in the expected distribution of referred pain from a trigger point; and
• Taut band palpable in an accessible muscle when the trigger point is myofascial; and
• Exquisite spot tenderness at one point along the length of the taut band when the pain is myofascial; and
• Some degree of restricted range of motion of the involved muscle or joint, when measurable; and
• The above specific criteria are associated with at least ONE of the following MINOR CRITERIA:
  • Reproduction of clinical pain complaint or altered sensation by pressure on the tender spot; or
  • Local response (twitch) elicited by snapping palpation at the tender spot or by needle insertion into the tender spot; or
  • Pain alleviation by elongating (stretching) the muscle or by injecting the tender spot.

Trigger point injections (TPI) with a local anesthetic with or without steroid may be considered medically necessary for the treatment of pain associated with fibromyalgia when ALL of the American College of Rheumatology diagnostic criteria for fibromyalgia are met. These are:

• History of widespread pain for at least 3 months. To be considered wide spread, the pain must be present on both right and left sides and both above and below the waist.  In addition axial skeletal pain (cervical spine or anterior chest or thoracic spine or low back) must be present. In this definition, shoulder and buttock pain is considered as pain for each involved side. "Low back pain" is considered lower segment pain; and
• Pain, on digital palpation, must be present in at least 11 of the following 18 sites:
  • Occiput: Bilateral, at the suboccipital muscle insertions;
  • Low cervical: bilateral, at the anterior aspects of the intertransverse spaces at C5-C7;
  • Trapezius: bilateral, at the midpoint of the upper border;
  • Supraspinatus: bilateral, at origins, above the scapula spine near the medial border;
  • Second rib: bilateral, at the second costochondral junctions, just lateral to the junctions on upper surfaces;
  • Lateral epicondyle: bilateral, 2 cm distal to the epicondyles;
  • Gluteal: bilateral, in upper outer quadrants of buttocks in anterior fold of muscle;
  • Greater trochanter: bilateral, posterior to the trochanteric prominence;
  • Knee: bilateral, at the medial fat pad proximal to the joint line.

TPI Schedule

The following schedule for trigger point injections may be considered medically necessary when the previous criteria are met:

• In the diagnostic or stabilization phase, individuals may receive injections at intervals of no sooner than one week and preferably two weeks. The number of trigger point injections should be limited to no more than four (4) times per year for the diagnostic or stabilization phase.
• In the treatment or therapeutic phase, trigger point injections should continue only if the previous diagnostic injections provided pain relief and the frequency should be two (2) months or longer between each injection. The previous injections should have provided at least greater than 50% relief of pain for a period of at least six (6) weeks. The injections should be repeated only as necessary based on the medical necessity criteria (see above) and these should be limited to a maximum of six (6) times for local anesthetic and steroid injection.
• Under unusual circumstances such as a recurrent injury or cervicogenic headache, trigger point injections may be repeated at intervals of six (6) weeks after stabilization in the treatment phase.

Trigger point injections are considered not medically necessary in the presence of:

• Systemic infections; or
• Bleeding tendencies (including individuals undergoing anticoagulation therapy); or
• Other concomitant unstable medical conditions.

"Dry needling" trigger point stimulation is considered not medically necessary.

When ultrasound guidance (76942) is reported in conjunction with trigger point injections (20552 or 20553), only one (1) unit of service will be reimbursed per date of service regardless of the number of trigger points injections performed.

A trigger point injection is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

• Link to Provider Resource Center for the Medical Policy Update

06/2015, Dry Needling of Trigger Point Injections Not Medically Necessary
06/2015, Ultrasound Guidance Reported With Trigger Point Injections

• Link to Diagnosis Codes

• Link to References