Clinical UM Guideline


Subject:Trigger Point Injections
Guideline #:  CG-SURG-17Current Effective Date:  07/09/2013
Status:ReviewedLast Review Date:  05/09/2013

Description   

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.  Dry needling of a trigger point is a technique for pain treatment in which the pain site is stimulated by insertion of a needle without injection of medication.   

Clinical Indications  

Medically Necessary:

  1. Trigger point injections (TPI) with a local anesthetic with or without steroid are 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.
  2. Trigger point injections (TPI) with a local anesthetic with or without steroid are considered medically necessary for the treatment of pain associated with fibromyalgia when 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;  
    • 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. 
  3. The following schedule for trigger point injections is 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 injections.
    • 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.

Not Medically Necessary: 

Trigger point injections are considered not medically necessary in the presence of:

"Dry needling" trigger point stimulation is considered not medically necessary.

Coding

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes.  A draft of future ICD-10 Coding (effective10/01/2014) related to this document, as it might look today, is included below for your reference.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT 
20552Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)
20553Injection(s); single or multiple trigger point(s), 3 or more muscle(s)
97139Unlisted therapeutic procedure [when specified as dry needling]
  
ICD-9 Diagnosis 
 All diagnoses
  
ICD-10 DiagnosisICD-10-CM draft codes; effective 10/01/2014:
 All diagnoses
  
Discussion/General Information

Although not supported by rigorous randomized controlled trials (Cummings 2001), trigger point injections with a local anesthetic with or without a steroid are considered an accepted therapy for pain associated with myofascial pain syndrome or fibromyalgia.  

In a Cochrane review, Peloso and colleagues (2011) examined the effects of medication and injections on primary outcomes (e.g. pain) for adults with mechanical neck disorders and whiplash.  In their data analysis, they found that lidocaine injection into myofascial trigger points appears effective in two trials.

In another Cochrane review, Staal and colleagues (2011) performed a data analysis to determine if injection therapy is more effective than placebo or other treatments for patients with subacute or chronic low-back pain.  Based on these results, the review authors concluded that there is no strong evidence for or against the use of any type of injection therapy for individuals with subacute or chronic low-back pain.

Kim and colleagues (2012) evaluated the therapeutic effectiveness of trigger point injections into the muscles around the groin in males with clinically diagnosed chronic prostatitis (CP) and chronic pelvic pain syndrome (CPPS).  In addition, the researchers attempted to determine which muscle was the cause of groin pain by using ultrasound guidance during the injection.  Twenty-one (21) participants ranging in ages from 20 to 61 years met the inclusion criteria.  The NIH-CPSI score and the VAS were the main outcome measurements.  Trigger point injections were performed in all affected muscles at 1-week intervals.  Additional injections were not considered if the participants were satisfied with the reduction in discomfort or the severity of pain, or if the individual did not want another injection for other reasons.  No other therapies (such as physical therapy or medications) were allowed during the study period.  However, self-exercise and behavior correction were allowed to avoid early recurrence of pain after trigger point injections.  Of the 21 participants, all completed the treatment schedule and attended a follow-up. Fourteen participants (66.7%) received one trigger point injection, six participants (28.6%) received two injections at an interval of 1 week, and one subject (4.7%) received a total of three injections at the same interval.  Nineteen of the 21 participants reported improvement of symptoms enough to not need further treatment, while 2 subjects did not complete the injection treatment for personal reasons.  With all of the subjects, the VAS and NIH-CPSI scores decreased compared with the baseline scores.  The participants did not report any complications related to the injections or serious adverse events attributable to the treatment.  The authors concluded that US-guided trigger point injections of the iliopsoas, hip adductor, and abdominal muscles are safe and effective for CP/CPPS groin pain which is believed to originate from muscles.  The iliopsoas muscle was affected in all of the participants in this study.  The authors acknowledged that limitations of this study include its small size and short follow-up time.

There is little evidence to support dry needling.  A Cochrane assessment of dry needling for lower back pain found that while dry-needling may be a useful adjunct to other therapies, most of the limited number of studies available were of low methodological quality and small sample size (Furlan, 2000).

Karakurum and colleagues (2001) studied dry needling for tension type headaches (TTH).  Fifteen participants with TTH received intramuscular dry needle insertions into six designated trigger points, while fifteen controls received sham dry needle subcutaneous insertions.  Results showed significant improvement of mean headache indices after treatment, both in the treatment group and in the placebo group, but the difference between the two groups was not statistically significant.  In the treatment group, neck tenderness and range of motion improved, while there was no significant improvement in the sham placebo group.  However, the number of participants treated was too small for this difference to be statistically significant.  The authors concluded that more and larger controlled, comparative trials were needed to show whether the dry-needle technique is effective in the treatment of TTH.

Irnich and colleagues (2002) compared the effects of dry needling and acupuncture at distant points in chronic neck pain using a randomized, double-blind, sham controlled cross-over trial.  Thirty-six participants were included in the prospective trial.  Although an assessment of change revealed acupuncture was superior to both sham and dry needling, there was no difference between dry needling and sham control. (P=0.8).

Kamanlia and colleagues (2005) reported a prospective single blind study comparing trigger point injection for myofascial pain syndrome using lidocaine injection, botulinum toxin type A (BTX-A) injection and dry needling.  Twenty-nine participants were randomized to three groups of near equal size.  A variety of outcome measures were used including pain scores, trigger point pain pressure threshold (PPT), visual analog scales for pain (VAS), the Hamilton depression score and quality of life (QOL) assessments using the Nottingham Health Profile (NHP).  While pain pressure thresholds and pain scores improved in all three groups, the pain pressure threshold values were significantly higher in the lidocaine group than in the dry needle group.  VAS did not change in the dry needle group, but did decrease in the lidocaine injection and BTX-A injected groups.  QOL scores by NHP improved in the lidocaine and BTX-A groups but not in the dry needle group.  The limitations of this study include its small size and the lack of an untreated or sham control group. 

In 2009, Tough and colleagues published a systematic review and meta-analysis of randomized controlled trials addressing dry needling in the management of myofascial trigger point pain.  A meta-analysis was performed on four studies of 134 participants that included a placebo control. This analysis concluded that dry needling was not superior to placebo.  Other randomized studies reported conflicting findings.  The authors concluded the limited sample size and poor quality of these studies highlights and supports the need for large scale, good quality placebo controlled trials in this area.

References

Peer Reviewed Publications:

  1. Alvarez DJ, Rockwell PG. Trigger points: diagnosis and management. Am Fam Physician. 2002; 15; 65(4):653-660.
  2. Cummings TM, White AR. Needling therapies in the management of myofascial trigger point pain: a systematic review. Arch Phys Med Rehabil. 2001; 82(7):986-992.
  3. Huguenin L. Myofascial trigger points: the current evidence. Physical Therapy in Sport 5. 2004; 2-12.
  4. Irnich D, Behrens N, Gleditsch JM, et al. Immediate effects of dry needling and acupuncture at distant points in chronic neck pain: results of a randomized, double-blind, sham-controlled crossover trial.  Pain. 2002; 99 (1-2):83-89. 
  5. Kamanli A, Kaya A, Ardicoglu O, et al. Comparison of lidocaine injection, botulinum toxin injection, and dry needling to trigger points in myofascial pain syndrome. Rheumatol Int. 2005; 25(8):604-611.
  6. Karakurum B, Karaalin O, Coskun O, et al. The 'dry-needle technique': intramuscular stimulation in tension-type headache. 2001; 21(8):813-817.
  7. Kim DS, Jeong TY, Kim YK, et al. Usefulness of a Myofascial Trigger Point Injection for Groin Pain in Patients With Chronic Prostatitis/Chronic Pelvic Pain Syndrome: A Pilot Study. Arch Phys Med Rehabil. 2012 Dec 21. pii: S0003-9993(12)01244-0. doi: 10.1016/j.apmr.2012.12.011. [Epub ahead of print].
  8. 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 randomised controlled trials. Eur J Pain. 2009; 13(1):3-10.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Society of Anesthesiologists (ASA), American Society of Regional Anesthesia (ASRA). Practice guidelines for chronic pain management: an updated report Anesthesiology 2010; 112(4):810-833.
  2. American College of Occupational and Environmental Medicine (ACOEM). Chronic pain. In: Occupational medicine practice guidelines: evaluation and management of common health problems and functional recovery in workers. 2008; 73-502.
  3. Furlan AD, van Tulder MW, Cherkin DC, et al. Acupuncture and dry-needling for low back pain. Cochrane Database Syst Rev. 2000; (2):CD001351.
  4. Peloso PMJ, Gross A, Haines T, et al. Medicinal and injection therapies for mechanical neck disorders Cochrane Database Syst Rev. 2007, updated 2011; (4):CD000319 
  5. Resnick D, Choudhri T, Dailey A, et al. American Association of Neurological Surgeons. Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 13: injection therapies, low-back pain, and lumbar fusion. J Neurosurg: Spine 2005; 2(6):707–715.
  6. Scott A, Guo B. Trigger Point Injections for Chronic Non-Malignant Musculoskeletal Pain Health Technology Assessment (HTA) number 35.  Alberta Heritage Foundation for Medical Research. 2005.
  7. Staal JB, de Bie R, de Vet HCW, et al. Injection therapy for subacute and chronic low-back pain. Cochrane Database Syst Rev. 2008, updated 2011; (3):CD001824.
  8. Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology. 1990 criteria for the classification of fibromyalgia: Report of the multicenter criteria committee. Arthritis Rheum. 1990; 33(2):160-172.
Index

Dry Needling
Fibromyalgia
Myofascial Pain
Trigger Point

History
StatusDateAction
Reviewed05/09/2013Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Discussion/General Information and References sections. 
Reviewed05/10/2012MPTAC review. Discussion and References updated.
Reviewed05/19/2011MPTAC review. References and Coding updated.
Reviewed05/13/2010MPTAC review. References updated.
Reviewed05/21/2009MPTAC review. Discussion and references updated. Place of service removed.
Reviewed05/15/2008MPTAC review. References updated.
Revised05/17/2007MPTAC review. Guideline revised to address dry needling. Background, coding, and references updated.
Reviewed12/07/2006MPTAC review. References updated.
Revised12/01/2005MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization. 
Pre-Merger Organizations Last Review DateDocument NumberTitle

Anthem, Inc. 

  None
Anthem BCBS  None
WellPoint Health Networks, Inc.12/02/2004GuidelineRegional Anesthesia/Pain Management for Chronic Neck, Back and Myofascial Pain