Highmark Commercial Medical Policy - Pennsylvania

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Medical Policy: S-240-005
Topic: Trigger Point Injections
Section: Surgery
Effective Date: October 1, 2016
Issue Date: June 25, 2018
Last Reviewed: June 2018

Trigger points are small, circumscribed, hyperirritable foci in muscles, often found within a firm or taut band of skeletal muscle.  Frequently affected sites include the trapezius, supraspinatus, infraspinatus, teres major, lumbar paraspinals, gluteus and pectoralis muscles.  The diagnosis is clinical and depends upon the results of a detailed history and a thorough directed exam.  There is no laboratory or imaging test to establish the diagnosis of trigger point pain.

Myofascial pain syndrome is a regional painful muscle condition with a relationship between a specific trigger point and its associated pain region.  When myofascial pain syndrome is suspected, injections of local anesthetics with or without steroid into the identified trigger points have been used for myofascial pain management for many years within the medical community.

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.

Policy Position Coverage is subject to the specific terms of the member’s benefit plan.

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.


Procedure Codes
20552, 20553, 76942

Place of Service: Outpatient

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.

The policy position applies to all commercial lines of business

Denial Statements

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.


Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as:
    • Qualified interpreters
    • Information written in other languages
If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

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