Sunflower Health Plan Trigger Point Injections for Pain Management (PDF) Form

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 It is the policy of health plans affiliated with Centene Corporation® that invasive pain management procedures performed by a physician are medically necessary when the relevant criteria are met and the patient receives only one procedure per visit, with or without radiographic guidance. I. Trigger point injections are medically necessary for the following indications: A. Diagnosis/stabilization of trigger points with injections of corticosteroids and/or local anesthetics at the trigger point, all of the following: 1. The member/enrollee has local pain symptoms in the neck, shoulder and/or back that have persisted for more than 3 months causing tenderness and/or weakness, restricting motion and/or causing referred pain when compressed; 2. The member/enrollee has failed ≥ 3 weeks of conventional multidisciplinary medical therapy including all of the following: a. Chiropractic, physical therapy, or prescribed home exercise program or the member/enrollee is unable to tolerate such therapy and the injection is intended as a bridge to therapy; b. NSAID, unless contraindicated or not tolerated; c. Activity modification; 3. Trigger points have been identified by palpation; 4. Trigger points are located in a few discrete areas and are not associated with widespread areas of muscle tenderness (as with fibromyalgia); 5. Injections are not used as sole method of treatment, rather are intended for pain relief to facilitate mobilization to allow non-invasive modalities, e.g., physical therapy and other alternate therapies that address muscle strengthening, flexibility, and functional restoration. Up to 2 sets of injections at least 7 days apart may be given for diagnosis and stabilization for the same trigger point. When a given body region is injected, it will be considered as one injection service no matter how many injections are given. B. Additional trigger point injections (up to 4), all of the following: 1. Prior injections resulted in ≥ 50% pain relief with functional improvement for ≥ 6 weeks; 2. There was a return of pain and/or deterioration following ≥ 6 weeks of improvement; Page 1 of 6 CLINICAL POLICY Trigger Point Injections 3. Injections are given in the neck, shoulder, and/or back; 4. Injections are given at least 2 months apart for up to 12 months from the initial injection (maximum of 6 total sessions); 5. 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. II. 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, hyperirritative 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. Trigger point injections of local anesthetic and/or steroids are 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 3 trials.1-3 Another systematic review found that intramuscular injection of lidocaine more effectively relieved neck pain in the short term than placebo.4 A systematic review of trigger point injections with botulinum toxin concluded that a statistically or clinically significant benefit could not be confirmed from the use of botulinum toxin-A used alone for chronic neck pain in the short term.6 Secondary outcomes such as pain, disability, and quality of life were also investigated without confirmed benefit of botulinum injections.6 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.7 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 2020, American Medical Association. All rights reserved. CPT codes and CPT descriptions are Page 2 of 6 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 20552 20553 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) Injection(s); single or multiple trigger point(s), 3 or more muscles CPT codes that do not support coverage criteria CPT® Codes 20560 Needle insertion(s) without injection(s); 1 or 2 muscle(s) 20561 Needle insertion(s) without injection(s); 3 or more muscles - ICD-10-CM Diagnosis Codes that Support Coverage Criteria + Indicates a code requiring an additional character ICD 10 CM Code - M25.511 through M25.519 M54.5 M54.9 M79.12 M79.18 Low back pain Dorsalgia, unspecified Myalgia of auxiliary muscles, head and neck Myalgia, other site Pain in shoulder Reviews, Revisions, and Approvals Policy split from CP.MP.118 Injections for Pain Management. Minor rewording for clarity. Background updated. References reviewed and updated. Specialist review. CPT 20560 and 20561 added as not supporting coverage criteria. 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. 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 with member/enrollee. Reviewed by specialist. 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 Revision Date 08/18 Approval Date 08/18 07/19 04/20 08/20 08/19 08/20 08/21 08/21 08/22 08/22 Page 3 of 6 CLINICAL POLICY Trigger Point Injections Reviews, Revisions, and Approvals Revision Date Approval Date added “from initial injection” and changed maximum of 4 total sessions to 6. Specialist review.