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Trigger Point Injections
MA11.017j

Policy

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.

MEDICALLY NECESSARY

Trigger point injections with anesthetic and/or corticosteroids 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 12 sessions in a 12-month period.

NON-COVERED

Trigger point injection without the injection of medication, also known as dry needling, for conditions including the treatment of myofascial pain, is not covered by the Company because it is a service not covered by Medicare because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature. Therefore, it is not eligible for reimbursement consideration.

For dry needling/acupuncture refer to the Acupuncture policy.


NOT MEDICALLY NECESSARY

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.

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)
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.

Trigger point injection CPT codes 20552 and 20553 must be reported with an appropriate drug code (i.e., anesthetic, corticosteroid).

Guidelines

It is expected that trigger point injections would not usually be performed more than three sessions in a three-month period.

This policy is consistent with Medicare's coverage determination for trigger point injections. The Company's payment methodology may differ from Medicare.

There is no Medicare coverage position for the use of trigger point injections in the treatment of temporomandibular joint disorder; therefore, the Company policy is applicable.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, trigger point injections are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

Subject to the applicable Evidence of Coverage, dry needling of trigger points for the treatment of myofascial pain is not eligible for payment under the medical benefits of the Company's Medicare Advantage products because the service is considered not covered.

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.

PEER-REVIEWED LITERATURE

In 2015, Liu et al. in a systematic review and meta-analysis evaluated the effectiveness of dry needling of myofascial trigger points associated with neck and shoulder pain. The authors concluded dry needling can be recommended for relieving myofascial trigger point pain in the neck and shoulders in the short and medium term, but wet needling is found to be more effective than dry needling in relieving myofascial trigger point pain in the neck and shoulders in the medium term.

In 2016, Morihisa et al. in a systematic review evaluated the use of dry needling as an intervention for lower quarter trigger points in patients with various orthopedic conditions. The authors concluded dry needling is effective in reducing pain associated with lower quarter trigger points in the short-term. However, the findings suggest dry needling does not have a positive effect on function, quality of life, depression, range of motion, or strength. Further high-quality research with long-term follow-up investigating the effect of dry needling in comparison to and in conjunction with other interventions is needed to determine the optimal use of dry needling in treating patients with lower quarter trigger points.


In a parallel randomized clinical trial, Perez-Palomeres et al. (2017) investigated the effectiveness of dry needling in addition to evidence-based personalized physical therapy in the treatment of shoulder pain. One hundred twenty individuals with nonspecific shoulder pain were randomly allocated into two parallel groups: a personalized, evidence-based physical therapy treatment and a trigger point dry needling in addition to the personalized, evidence-based physical therapy. Sixty-three individuals were randomly assigned to the control group and 57 were assigned to the interventional group. Individuals were assessed at baseline, post-treatment, and at a three-month follow-up. The authors concluded there were no significant differences in outcome between the two treatment groups. Both groups showed improvement over time; therefore, dry needling did not offer additional benefits to personalized, evidence-based physical therapy for individuals with nonspecific shoulder pain.


In a randomized clinical trial, De Meulemeester et al. (2017) studied the short-term and long-term treatment effects of dry needling and manual pressure technique with the primary goal of determining if dry needling had better effects on disability, pain, and muscle characteristics in treating myofascial neck/shoulder pain in women. Forty-two female office workers with myofascial neck/shoulder pain were randomly allocated to either a dry needling or manual pressure group and received four treatments. They concluded there was no significant difference between dry needling and manual pressure. Both treatment techniques lead to short-term and long-term treatment effects. In both groups, after the 4-week treatment program, there was a significant improvement in pain pressure threshold, muscle elasticity, and stiffness. Dry needling was found to be no more effective than manual pressure in the treatment of myofascial neck/shoulder pain.

In 2017, Espejo-Antunez et al. in a systematic review of randomized controlled trials examined the effectiveness of dry needling in the treatment of myofascial trigger points. The authors concluded that, despite some evidence suggesting dry needling is effective in the short term for pain relief and increased range of motion, further randomized clinical trials of high methodological quality using standardized procedures for the application of dry needling are needed.

References

American Physical Therapy Association (APTA). Description of dry needling in clinical practice: an educational resource paper. Feb. 2013; Available at:  https://www.mptalliance.com/wp-content/uploads/2015/12/APTA-DN_ClinicalPracticeEducationalResourcePaper.pdf. Accessed June 10, 2022.

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.

Centers for Medicare & Medicaid Services (CMS). Department of Health and Human Services. Medicare Program; CY 2020 Revisions to Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements; Medicaid Promoting Interoperability Program Requirements for Eligible Professionals; Establishment of an Ambulance Data Collection System; Updates to the Quality Payment Program; Medicare Enrollment of Opioid Treatment Programs and Enhancements to Provider Enrollment Regulations Concerning Improper Prescribing and Patient Harm; and Amendments to Physician Self-Referral Law Advisory Opinion Regulations Final Rule; and Coding and Payment for Evaluation and Management, Observation and Provision of Self-Administered Esketamine Interim Final Rule. 11/15/2019. Available at:
https://www.federalregister.gov/documents/2019/11/15/2019-24086/medicare-program-cy-2020-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other. Accessed June 10, 2022.

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.

De Meulemeester K, Castelein B, Coppieters I, et al. Comparing trigger point dry needling and manual pressure technique for the management of myofascial neck/shoulder pain: a randomized clinical trial. J Manipulative Physiol Ther. 2017; 40(1): 11-20.

Espejo-Antunez L, Tejeda JF, Albornoz-Cabelto M et al. Dry needling in the management of myofascial trigger points: a systematic review of randomized controlled trials. Complement Ther Med. 2017; 33: 46-57.

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.

Liu L, Huang QM, Liu QG, et al. Effectiveness of dry needling for myofascial trigger points associated with neck and shoulder pain: a systematic review and meta-analysis. Arch Phys Med Rehab. 2015; 96(5): 944-955.

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.

Morihisa R, Eskew J, McNamara A, et al. Dry needling in subjects with muscular trigger points in the lower quarter: a systematic review. Int J Sports Phys Ther. 2016; 11(1): 1-4.

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 Article (A57751). Billing and coding: trigger point injections. [Novitas web site]. Original: 11/21/2019. Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=57751&ver=20&bc=0. Accessed June 10, 2022.

Novitas Solutions, Inc. Local Coverage Determination (LCD). L35010: Trigger point injections. [Novitas Solutions Web site]. Original: 10/01/15. (Revised: 11/21/2019). Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=35010&ver=36&bc=0. Accessed June 10, 2022.

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

Perez-Palomares S, Olivan-Blazquez B, Perez-Palomares A, et al. Contribution of dry needling to individualized physical therapy treatment of shoulder pain: a randomized clinical trial. J Orthop Sports Phys Ther. 2017; 47(1):11-20.

Rha DW, Park GY, Kim YK, et al. Comparison of the therapeutic effects of ultrasound guided 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

CPT Procedure Code Number(s)
MEDICALLY NECESSARY

20552, 20553

NOT COVERED
​
20560, 20561
ICD - 10 Procedure Code Number(s)
N/A
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
M54.50 Low back pain, unspecified
M54.51 Vertebrogenic low back pain
M54.59 Other 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

J1010 Injection, methylprednisolone 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

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

Acupuncture is not a covered service even if provided for the treatment of an established trigger point.

The use of acupuncture needles and/or the passage of electrical current through these needles is not covered (whether an acupuncturist or other provider renders the service).

Billing under the trigger point injection code for prolotherapy is a misrepresentation of the actual service rendered.

Policy History

Revisions From MA11.017j:​​
​04/30/2025

​The policy has been reviewed and reissued to communicate the Company's continuing position on Trigger Point Injections​.​
04/01/2025This version of the policy will become effective 04/01/2025.

The following HCPCS code has been deleted and removed from this policy:

J1094 Injection, dexamethasone acetate, 1 mg​


Revisions From MA11.017i:​
​07/24/2024

​The policy has been reviewed and reissued to communicate the Company's continuing position on Trigger Point Injections.​​
04/01/2024This version of the policy will become effective 04/01/2024.

The following HCPCS codes have been termed (no longer valid codes) and removed from this policy:

J1020 Injection, methylprednisolone acetate, 20 mg

J1030 Injection, methylprednisolone acetate, 40 mg

J1040 Injection, methylprednisolone acetate, 80 mg


The following HCPCS​ code has been added to this policy:


J1010 Injection, methylprednisolone acetate, 1 mg

Revisions From MA11.017h:
​01/01/2024
​Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.​
​03/08/2023

​This policy has been reissued in accordance with the Company's annual review process.​​
07/27/2022

The policy has been reviewed and reissued to communicate the Company's continuing position on Trigger Point Injections.
​10/01/2021
​The version of this policy will become effective 10/01/2021. 
The following ICD-10 CM code has been termed from this policy:
M54.5: Low back pain

The following ICD-10 CM codes have been added to this policy as Medically Necessary:
M54.50: Low back pain, unspecified
M54.51: Vertebrogenic low back pain
M54.59: Other low back pain​

Revisions From MA11.017g:
06/16/2021The policy has been reviewed and reissued to communicate the Company's continuing position on Trigger Point Injections​.
​11/30/2020

​The version of this policy will become effective 11/30/2020.
In accordance with Medicare, the policy has been updated to reflect a change in position for dry needling of trigger points for myofascial pain from medically necessary to non-covered per CMS New Final Rule.

In accordance with Medicare, CPT codes 20560 and 20561 are​ non-covered.

Revision From MA11.017f:
01/01/2020 This policy has been identified for the CPT code update, effective 01/01/2020.

The following CPT codes have been added to the policy:

20560; 20561 (Medically Necessary)

Revision From MA11.017e:
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 12 sessions in a 12-month period.

Revisions From MA11.017d:
01/10/2018This 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.

Revisions From MA11.017c:
06/21/2017This policy has been reissued in accordance with the Company's annual review process.
01/13/2017This version of the policy will become effective 01/13/2017.
The policy has been reviewed to communicate the Company’s continuing positions on Trigger Point Injections.

The ICD-10 CM laterality codes have been added to this policy.
Policy is diagnosis-linked

Revisions From MA11.017b:
10/01/2016This version of the policy will become effective 10/01/2016.
This policy has been identified for the ICD-10 CM code update, effective 10/01/2016.

The following ICD-10 CM codes have been deleted from this policy:
    M26.60, M26.61, M26.62 M26.63
The following ICD-10 CM codes have been added to this policy:
    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

Revisions From MA11.017a:
03/04/2015This policy will become effective 03/04/15.

The following ICD-9 CM and ICD-10 codes have been removed from this policy:
  • ICD-9
    • 726.13 Partial tear of rotator cuff
  • ICD-10
    • M75.111 Incomplete rotator cuff tear or rupture of right shoulder, not specified as traumatic
    • M75.112 Incomplete rotator cuff tear or rupture of left shoulder, not specified as traumatic

Revisions From MA11.017:
01/01/2015This is a new policy.

4/1/2024
4/1/2024
4/30/2025
MA11.017
Medical Policy Bulletin
Medicare Advantage
No
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Independence Blue Cross is a subsidiary of Independence Health Group, Inc. — independent licensees of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.