Clinical Policy: Trigger Point Injections for Pain Management Form

CENTENE
Corporation

Clinical Policy: Trigger Point Injections for Pain Management
Reference Number: CP.MP.169
Date of Last Revision: 07/24
Coding Implications
Revision Log

See Important Reminder at the end of this policy for important regulatory and legal information.

Description
Trigger points cause pain at their physical location as well as referred pain to other areas in a specific pattern. Trigger point injections consist of an injection of a local anesthetic, with or without steroid medication, into a painful portion of the muscle containing the trigger point.

Policy/Criteria

II. It is the policy of health plans affiliated with Centene Corporation that additional trigger point injections (up to four) are medically necessary when all of the following criteria are met:
A. Prior injections resulted in ≥ 50% pain relief with functional improvement for ≥ 6 weeks;
B. There was a return of pain and/or deterioration following ≥ 6 weeks of improvement;

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CENTENE
Corporation

CLINICAL POLICY
Trigger Point Injections

C. Injections are given at least two months apart for up to 12 months from the initial injection (maximum of six total sessions);
D. Injections are not used as sole method of treatment, but rather are intended for pain relief to facilitate mobilization to allow for non-invasive modalities, e.g., physical therapy and other alternate therapies that address muscle strengthening, flexibility, and functional restoration.

When a given body region is injected, it will be considered as one injection service no matter how many injections are given.

III.It is the policy of health plans affiliated with Centene Corporation that current evidence does not support the use of trigger point therapies for the following indications, because although there are ongoing studies, there is little scientifically based data suggesting their use results in improved patient outcomes in the medical literature:
A. Dry needle stimulation of trigger points;
B. Trigger point injection with saline or glucose;
C. The use of Botox during trigger point injections.

Background
A trigger point is a discrete, hyperirritable focus found in a palpable taut band occurring in any skeletal muscle and/or muscle fascia on the body that is particularly sensitive to touch and, when compressed, gives rise to characteristic referral pain patterns, tenderness, and autonomic phenomena. Trigger points are thought to result from repetitive strain produced by acute or chronic overload or a degenerative and/or inflammatory problem, such as arthritis.¹

Trigger point injections of local anesthetic and/or steroids is a common intervention for back and neck pain, although evidence is mixed. A Cochrane review of injections for subacute and chronic back pain found no clear advantage of local or trigger point injections with a local anesthetic, with or without a corticosteroid, and control interventions for short-term pain relief across three trials.²,³,⁴,⁵,⁶ The North American Spine Society (NASS) concluded there is insufficient evidence to make a recommendation for or against the use of trigger point injections in the treatment of low back pain and that the type of injectate does not influence outcomes.⁷

A systematic review of trigger point injections with botulinum toxin concluded that a statistically or clinically significant benefit could be confirmed from the use of botulinum toxin-A used alone for chronic neck pain in the short term. Secondary outcomes such as pain, disability, and quality of life were also investigated without confirmed benefit of botulinum injections.⁸

There is preliminary evidence that dry needling of trigger points is effective for short-term pain relief, and to improve quality of life and range of motion when compared to a placebo, but further studies of high quality and with a standardized needling procedure are needed.⁵,⁹

Coding Implications
This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2023, American Medical Association. All rights reserved. CPT codes and CPT descriptions are

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CENTENE
Corporation

CLINICAL POLICY
Trigger Point Injections

from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services.

CPT codes that support coverage criteria

CPT codes that do not support coverage criteria

Reviews, Revisions, and Approvals | Revision Date | Approval Date --- | --- | --- Policy split from CP.MP.118 Injections for Pain Management. Minor rewording for clarity. Background updated. | 08/18 | 08/18 CPT 20560 and 20561 added as not supporting coverage criteria. | 04/20 | I.B.4: Changed maximum of 6 injections/year to 4. Added ICD-10 code M79.18 and changed M79.1 to M79.12. References reviewed and updated. | 08/20 | 08/20 Annual review. Referenced reviewed and updated. Updated criteria II. to replace “not medically necessary” with “current evidence does not support.” Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” Replaced member/enrollee with member/enrollee. Reviewed by specialist. | 08/21 | 08/21 Annual review. References reviewed, updated, and reformatted. Updated criteria in I.B. from 2 additional injections to 4. In I.B.1 added pain relief with functional improvement, in I.B.2 added “≥ 6 weeks, and in I.B.4 added “from initial injection” and changed maximum of 4 total sessions to 6. Specialist review. | 08/22 | 08/22 Annual review completed. Minor rewording with no clinical significance. Background updated. ICD-10 Diagnosis code table removed. References reviewed and updated. | 08/23 | 08/23 Annual review. Removed “with or without radiographic guidance” language in Criteria I.A. Criteria I.A.1. updated to state “myofascial pain.” Removed Criteria I.C. regarding location of trigger point injection in the neck, shoulder, and/or back. Background updated with no impact to criteria. References reviewed and updated. Reviewed by internal specialist and external specialist. | 07/24 | 07/24

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CENTENE
Corporation

CLINICAL POLICY
Trigger Point Injections

14. Local coverage determination: trigger point injections (L39713). Centers for Medicare and Medicaid Services Web site. http://www.cms.hhs.gov/mcd/search.asp. Published April 01, 2024. Accessed June 20, 2024.

Important Reminder

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CENTENE
Corporation

CLINICAL POLICY
Trigger Point Injections

This clinical policy has been developed by appropriately experienced and licensed health care professionals based on a review and consideration of currently available generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by this clinical policy; and other available clinical information. The Health Plan makes no representations and accepts no liability with respect to the content of any external information used or relied upon in developing this clinical policy. This clinical policy is consistent with standards of medical practice current at the time that this clinical policy was approved. “Health Plan” means a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan’s affiliates, as applicable.

The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions, and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as to state and federal requirements and applicable Health Plan-level administrative policies and procedures.

This clinical policy is effective as of the date determined by the Health Plan. The date of posting may not be the effective date of this clinical policy. This clinical policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this clinical policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. The Health Plan retains the right to change, amend or withdraw this clinical policy, and additional clinical policies may be developed and adopted as needed at any time.

This clinical policy does not constitute medical advice, medical treatment, or medical care. It is not intended to dictate to providers how to practice medicine. Providers are expected to exercise professional medical judgment in providing the most appropriate care and are solely responsible for the medical advice and treatment of member/enrollees. This clinical policy is not intended to recommend treatment for member/enrollees. Member/enrollees should consult with their treating physician in connection with diagnosis and treatment decisions.

Providers referred to in this clinical policy are independent contractors who exercise independent judgment and over whom the Health Plan has no control or right of control. Providers are not agents or employees of the Health Plan.

This clinical policy is the property of the Health Plan. Unauthorized copying, use, and distribution of this clinical policy or any information contained herein is strictly prohibited. Providers, member/enrollees, and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, member/enrollees and their representatives agree to be bound by such terms and conditions by providing services to member/enrollees and/or submitting claims for payment for such services.

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CENTENE
Corporation

CLINICAL POLICY
Trigger Point Injections

Note: For Medicaid member/enrollees, when state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this clinical policy.

Note: For Medicare member/enrollees, to ensure consistency with the Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), all applicable NCDs, LCDs, and Medicare Coverage Articles should be reviewed prior to applying the criteria set forth in this clinical policy. Refer to the CMS website at http://www.cms.gov for additional information.

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