Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Trigger Point Injections

Policy #:11.14.02n

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract. The Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition.

Trigger point injections are considered medically necessary, and, therefore, covered for myofascial pain syndrome (MPS) when at least one of the following criteria are met, in accordance with the maximum number list below:
  • Noninvasive medical management (e.g., analgesics, passive physical therapy, ultrasound therapy, range of motion, and/or active exercises) is unsuccessful.
  • Joint movement is mechanically blocked, as when the coccygeus muscle is involved.
  • As a bridging therapy to relieve pain while other treatments are being initiated, such as physical therapy or medication or as a single therapeutic maneuver.

Trigger point injections are considered medically necessary, and, therefore, covered for myofascial pain syndrome (MPS) for a maximum number of ten sessions in a 12-month period.

Dry needling of trigger points is considered medically necessary and, therefore, covered. The medical necessity criteria for dry needling of trigger points are the same as those for trigger point injections.

All other uses for trigger point injections are considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support their use in the diagnosis or treatment of illness or injury.

BILLING REQUIREMENTS

Reporting prolotherapy as a trigger point injection or any other service or procedure is a misrepresentation of the actual service rendered. These services are subject to post-payment review and audit procedures. The appropriate code for prolotherapy is M0076.

Only one of the Current Procedural Terminology (CPT) codes 20552 or 20553 should be reported on any particular day, no matter how many sites or regions are injected.

One session is considered administration of injection services to a particular site, regardless of the number of injections.

Medications listed in the Coding Table are eligible for separate reimbursement when used for trigger point injections that meet the medical necessity criteria listed in this policy.

To report dry needling, use the appropriate codes for trigger point injection.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

When requested, medical documentation for trigger point injections must include the following:
  • Proper evaluation leading to a diagnosis of myofascial pain syndrome (MPS), and any extenuating circumstances (e.g., level of pain, interruption of activities of daily living)
  • Identification of the affected muscle(s) and the region of each injection
  • The reason for selecting this therapeutic option, as well as the previous treatments utilized
  • The drugs injected and the dosage of each drug
  • The benefits received from the prior set(s) of injections (to establish the need for subsequent injections)

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, trigger point injection is covered under the medical benefits of the Company's products when the medical necessity criteria listed in this medical policy are met.

Description

Trigger point injection is one of many modalities utilized in the management of chronic pain. The goal is to treat the cause of the pain and not just the symptom of pain. Myofascial trigger points are self-sustaining hyperirritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic overload. These trigger points produce a referred pain pattern characteristic for that individual muscle. Each pattern becomes part of a single muscle myofascial pain syndrome (MPS), and each of these single muscle syndromes is responsive to appropriate treatment, which includes injection therapy. Injection is achieved with needle insertion and the administration of agents, such as local anesthetics, steroids, and/or local anti-inflammatory drugs.

The diagnosis of trigger points requires a detailed history and thorough physical examination. The following clinical symptoms may be present when making the diagnosis:
  • History of onset of the painful condition and its presumed cause (e.g., injury and sprain)
  • Distribution of pattern of pain consistent with the referral pattern of trigger points
  • Range-of-motion restriction
  • Muscular deconditioning in the affected area
  • Focal tenderness of a trigger point
  • Palpable taut band of muscle in which trigger point is located
  • Local taut response to snapping palpation
  • Reproduction of referred pain pattern upon stimulation of trigger point

Dry needling is a variant of trigger point therapy that uses only needles to stimulate trigger points and alleviate pain; no medications are injected into the affected area. Dry needling is different from acupuncture in that acupuncture stimulates distant points or meridians.
References


American Physical Therapy Association (APTA). Description of dry needling in clinical practice: an educational resource paper. Feb . 2013; http://www.apta.org/StateIssues/DryNeedling/ClinicalPracticeResourcePaper/. Accessed December 6, 2018.

Ay S, Evcik, D, Tur, BS. Comparison of injection methods in myofascial pain syndrome: a randomized controlled trial. Clin Rheumatol. 2010;29(1):19-23.

Brennan KL, Allen BC, Maldonado YM. Dry needling versus cortisone injection in the treatment of greater trochanteric pain syndrome: a noninferiority randomized clinical trial. J Orthop Sports Phys Ther. 2017;47(4):232-239.

Bubnov, RV. The use of trigger point "dry" needling under ultrasound guidance for the treatment of myofascial pain (technological innovation and literature review). Lik Sprava. 2010;(5-6):56-64.

Cummings TM, White AR. Needling therapies in the management of myofascial trigger point pain: A systematic review. Archiv Phys Med Rehab. 2001;82(7):986-992.

Fernandez-Carnero, J, La, TR, Ortega-Santiago, R, et al. Short-term effects of dry needling of active myofascial trigger points in the masseter muscle in patients with temporomandibular disorders. J Orofac Pain. 2010;24(1):106-112.

Ga H, Choi JH, Park CH, Yoon, HJ. Dry needling of trigger points with and without paraspinal needling in myofascial pain syndromes in elderly patients. J Altern Complement Med. 2007;13(6):617-624.

Gonzalez-Iglesias J, Cleland JA, del RG-V, Fernandez-de-las-Penas C. Multimodal management of lateral epicondylalgia in rock climbers: a prospective case series. J Manipulative Physiol Ther 2011;34(9):635-642.

Hong CZ, Hsueh TC. Difference in pain relief after trigger point injections in myofascial pain patients with and without fibromyalgia. Arch Phys Med Rehabil. 1996;77(11):1161-1166.

Jayson MI. Fibromyalgia and trigger point injections. Bull Hosp Jt Dis. 1996;55(4):176-177.

Hopwood MB, Abram SE. Factors associated with failure of trigger point injections Clin J Pain. 1994;10(3):227-234.

Kietrys DM, Palombaro KM, Azzaretto E, et al. Effectiveness of dry needling for upper-quarter myofascial pain: a systematic review and meta-analysis. J Orthop Sports Phys Ther. 2013; 43(9):620-34.

Manchikanti L, Singh V, Kloth D, et al. Interventional techniques in the management of chronic pain: part 2.0. ASIPP Practice Guidelines. Pain Physician. 2001;4(1):24-98.

Myburgh C, Hartvigsen J, Aagaard P, Holsgaard-Larsen A. Skeletal muscle contractility, self-reported pain and tissue sensitivity in females with neck/shoulder pain and upper Trapezius myofascial trigger points--a randomized intervention study. Chiropr Man Therap. 2012;20(1):36.

Novitas Solutions, Inc. Local Coverage Determination (LCD). L35010: Trigger point injections. [Novitas Solutions Web site]. Original: 10/01/15. (Revised: 10/01/2018). Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35010&ver=20&name=314*1&UpdatePeriod=771&bc=AAAAEAABAAAA&. Accessed December 6, 2018.

Peloso P, Gross A, Haines T, et al. Medicinal and injection therapies for mechanical neck disorders. Cochrane Database Syst Rev. 2007;(3):CD000319.

Rha DW, Park GY, Kim YK, et al. Comparison of the therapeutic effects of ultrasoundguided platelet-rich plasma injection and dry needling in rotator cuff disease: a randomized controlled trial. Clin Rehabil. Ebub Oct. 3, 2012; 2013;27(2):113-22.

Scott NA, Guo B, Barton PM, Gerwin RD. Trigger point injections for chronic non-malignant musculoskeletal pain:A systematic review. Pain Med. 2009;10(1):54-69.

Srbely JZ, Dickey JP, Lee D, Lowerison M. Dry needle stimulation of myofascial trigger points evokes segmental anti-nociceptive effects. J Rehabil Med. 2010;42(5):463-468.

Tekin L, Akarsu S, Durmus O, et al. The effect of dry needling in the treatment of myofascial pain syndrome: a randomized double-blinded placebo-controlled trial. Clin Rheumatol. Epub Nov. 9, 2012; 2013;32(3):309-15.

Tough EA, White AR, Cummings TM, et al. Acupuncture and dry needling in the management of myofascial trigger point pain: a systematic review and meta-analysis of randomized controlled trials. Eur J Pain. 2009;13(1):3-10.

Tsai CT, Hsieh LF, Kuan TS, et al. Remote effects of dry needling on the irritability of the myofascial trigger point in the upper trapezius muscle. Am J Phys Med Rehabil.2010;89(2):133-140.

Venancio, RA, Alencar, FG, Jr., and Zamperini, C. Botulinum toxin, lidocaine, and dry-needling injections in patients with myofascial pain and headaches. Cranio.2009;27(1):46-53.

Wolfe F, Clauw DJ, Fitzcharles MA, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken). 2010;62(5):600-610.





Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

20552, 20553


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

M26.601 Right temporomandibular joint disorder, unspecified

M26.602 Left temporomandibular joint disorder, unspecified

M26.603 Bilateral temporomandibular joint disorder, unspecified

M26.609 Unspecified temporomandibular joint disorder, unspecified side

M26.611 Adhesions and ankylosis of right temporomandibular joint

M26.612 Adhesions and ankylosis of left temporomandibular joint

M26.613 Adhesions and ankylosis of bilateral temporomandibular joint

M26.619 Adhesions and ankylosis of temporomandibular joint, unspecified side

M26.621 Arthralgia of right temporomandibular joint

M26.622 Arthralgia of left temporomandibular joint

M26.623 Arthralgia of bilateral temporomandibular joint

M26.629 Arthralgia of temporomandibular joint, unspecified side

M26.631 Articular disc disorder of right temporomandibular joint

M26.632 Articular disc disorder of left temporomandibular joint

M26.633 Articular disc disorder of bilateral temporomandibular joint

M26.639 Articular disc disorder of temporomandibular joint, unspecified side

M26.69 Other specified disorders of temporomandibular joint

M53.82 Other specified dorsopathies, cervical region

M54.2 Cervicalgia

M54.5 Low back pain

M54.6 Pain in thoracic spine

M60.80 Other myositis, unspecified site

M60.811 Other myositis, right shoulder

M60.812 Other myositis, left shoulder

M60.819 Other myositis, unspecified shoulder

M60.821 Other myositis, right upper arm

M60.822 Other myositis, left upper arm

M60.829 Other myositis, unspecified upper arm

M60.831 Other myositis, right forearm

M60.832 Other myositis, left forearm

M60.839 Other myositis, unspecified forearm

M60.841 Other myositis, right hand

M60.842 Other myositis, left hand

M60.849 Other myositis, unspecified hand

M60.851 Other myositis, right thigh

M60.852 Other myositis, left thigh

M60.859 Other myositis, unspecified thigh

M60.861 Other myositis, right lower leg

M60.862 Other myositis, left lower leg

M60.869 Other myositis, unspecified lower leg

M60.871 Other myositis, right ankle and foot

M60.872 Other myositis, left ankle and foot

M60.879 Other myositis, unspecified ankle and foot

M60.88 Other myositis, other site

M60.89 Other myositis, multiple sites

M60.9 Myositis, unspecified

M75.80 Other shoulder lesions, unspecified shoulder

M75.81 Other shoulder lesions, right shoulder

M75.82 Other shoulder lesions, left shoulder

M79.10 Myalgia, unspecified site

M79.11 Myalgia of mastication muscle

M79.12 Myalgia of auxiliary muscles, head and neck

M79.18 Mylagia, other site

M79.7 Fibromyalgia




HCPCS Level II Code Number(s)


THIS IS NOT AN ALL-INCLUSIVE LIST OF DRUGS FOR USE WITH TRIGGER POINT INJECTIONS

J0702 Injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg

J1020 Injection, methylprednisolone acetate, 20 mg

J1030 Injection, methylprednisolone acetate, 40 mg

J1040 Injection, methylprednisolone acetate, 80 mg

J1094 Injection, dexamethasone acetate, 1 mg

J1100 Injection, dexamethasone sodium phosphate, 1 mg

J1700 Injection, hydrocortisone acetate, up to 25 mg

J2650 Injection, prednisolone acetate, up to 1 ml

J3301 Injection, triamcinolone acetonide, not otherwise specified, per 10 mg

J3302 Injection, triamcinolone diacetate, per 5 mg

J3303 Injection, triamcinolone hexacetonide, per 5 mg




Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

Revisions from 11.14.02n
06/05/2019This policy has been reissued in accordance with the Company's annual review process.
04/01/2019This version of the policy will become effective 04/01/2019. The following CPT codes have been revised in the policy: 20552, 20553. Policy section was updated to create a frequency limit of 10 injection sessions in a 12-month period.

Revisions from 11.14.02m
10/01/2018This version of the policy will become effective 10/01/2018. The following ICD-10 codes have been added to the policy: M79.10, M79.11, M79.12, M79.18. The following ICD-10 code have been termed from the policy: M79.1.


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 04/01/2019
Version Issued Date: 04/01/2019
Version Reissued Date: 06/05/2019

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.