Latest Review Date: May 2024 

Category:  Surgical                                                                

POLICY:

Trigger point injections with anesthetic and/or corticosteroid may be considered medically necessary for chronic neck or back pain or myofascial pain syndrome when:

• Trigger points have been identified by palpation on physical examination; and
• Symptoms have persisted despite failure of low grade conservative therapies (i.e., heating or cooling modalities, NSAIDS, analgesics); and
• In the treatment or therapeutic phase, further injections are covered only if the previous diagnostic injections provided at least 50% relief of pain.

Use of corticosteroids in more than four injections during a set of trigger point injections is considered not medically necessary.

Additional trigger point injections, including dry needling are considered not medically necessary when the patient does not experience symptom relief.

Ultrasound guidance and other imaging guidance of trigger points prior to or concurrent with trigger point injections is considered investigational.

**Conservative therapy is the use of structured physician-directed modalities which may include: prescription strength analgesics/anti-inflammatory medications if not contraindicated; participation in therapeutic physical medicine modality(ies) and/or manipulations when rendered by an eligible provider (including active exercise).

DESCRIPTION OF PROCEDURE OR SERVICE:

Trigger point injections (TPIs) are used to treat extremely painful areas of muscle. Normal muscle contracts and relaxes when it is active. Trigger points are discrete, focal, hyperirritable spots within a taut band of skeletal muscle fibers that produce local and/or referred pain when stimulated. Tender points also produce local pain when stimulated, but lack the taut band of tissue and hyperirritability when palpated. Scar tissue, loss of range of motion, and weakness may develop over time. Injection of an anesthetic agent or botulinum toxin into trigger points and tender points is being evaluated for the management of a variety of pain syndromes.

TPIs are used to alleviate myofascial pain syndrome (chronic pain involving tissue that surrounds muscle) that does not respond to other treatment, although there is some debate over its effectiveness. Myofascial pain syndrome is a chronic regional pain disorder caused by the activation of at least one trigger point in muscles, tendons, or muscle fascia. It can cause local or referred pain, tightness, tenderness, stiffness and limitation of movement, muscle weakness, and often autonomic phenomena. The severity of symptoms and degree of functional impairment vary. Some individuals will have few trigger points with mild symptoms and no functional impairment, while others will have multiple satellite trigger points, widespread and severe pain, and major functional impairments. Conditions that can lead to myofascial pain syndrome include chronic repetitive minor muscle strain, poor posture, systemic disease, strain, sprain, enthesopathy, and arthritis. Management of chronic myofascial pain typically includes behavioral and pharmacologic approaches and physical therapy. Injection of a local anesthetic or botulinum toxin has also been reported.

Note: Dry needling of trigger points are addressed separately in medical policy, #740 Dry Needling of Trigger Points.

KEY POINTS:

This policy has been updated regularly with searches of the MEDLINE database. The most recent literature update was performed through February 16, 2024.

Summary of Evidence.

For individuals who have myofascial pain syndrome who receive trigger point injections, the evidence includes several randomized controlled trials (RCTs) and a systematic review of RCTs. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. Lidocaine injections have been compared with physical therapy, lidocaine patches, sham stimulation, and dry needling. Some trials have reported that injecting lidocaine into trigger points improves subjective pain ratings to the same degree as physical therapy or lidocaine patches but only slightly more than sham stimulation. Other trials have found that lidocaine injection was superior to dry needling on subjective pain ratings but there was no significant benefit with lidocaine injection assessed on objective outcome measures. These results suggest a strong placebo effect of the treatment.

Clinical input was sought to help determine whether the use of trigger point injections for individuals with myofascial pain syndrome would provide a clinically meaningful improvement in net health outcome and whether the use is consistent with generally accepted medical practice. In response to requests, input was received from 6 specialty societies (10 reviewers) and 3 academic medical centers. There was general consensus that trigger point injections are considered medically necessary for select patients with myofascial pain syndrome who have failed conservative therapy when administered as part of a comprehensive therapy program. Input concurred that ultrasound guidance was investigational.

Clinical input concurred that ultrasound guidance was investigational. Evidence in the published medical literature evaluating the efficacy of adding ultrasound or other guidance to trigger point injections is limited. Due to the lack of high quality, peer-reviewed literature evaluating the efficacy of trigger point injection with and without guidance, the evidence is insufficient to determine an improvement in the net health outcome. Further clinical validation is needed to support the use of image guidance with trigger point injections.

Practice Guidelines and Position Statements

American Society of Anesthesiologists and the American Society of Regional Anesthesia and Pain Medicine

In 2010, the American Society of Anesthesiologists and the American Society of Regional Anesthesia and Pain Medicine published joint practice guidelines on chronic pain management. The 2 Societies found insufficient evidence to evaluate the efficacy of trigger point injections to provide pain relief compared with sham injections (category D evidence). Based on observational findings, the societies concluded that “trigger point injections may be considered for treatment of patients with myofascial pain as part of a multimodal approach to pain management.”

U.S Preventive Services Task Force Recommendations

Not applicable.

KEY WORDS:

Trigger point injections, TPIs, myofascial pain

APPROVED BY GOVERNING BODIES:

Although medications used with invasive trigger point and tender point procedures are regulated by the FDA, trigger and tender point injections are considered procedures and, as such, are not subject to regulation by FDA.

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits. Group-specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply

FEP contracts: Special benefit consideration may apply.  Refer to member’s benefit plan.  

CURRENT CODING:

CPT Codes:  

REFERENCES:

1. Affaitati G, Fabrizio A, Savini A, et al. A randomized, controlled study comparing a lidocaine patch, a placebo patch, and anesthetic injection for treatment of trigger points in patients with myofascial pain syndrome: evaluation of pain and somatic pain thresholds. Clin Ther. Apr 2009; 31(4): 705-20.
2. Alvarez DJ, Rockwell PG. Trigger points: diagnosis and management. Am Fam Physician. Feb 15 2002; 65(4): 653-60.
3. Benzon HT, Connis RT, De Leon-Casasola OA, et al. Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology. Apr 2010; 112(4): 810-33.
4. 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. Apr 2017; 47(4): 232-239.
5. Couto C, de Souza IC, Torres IL, et al. Paraspinal stimulation combined with trigger point needling and needle rotation for the treatment of myofascial pain: a randomized sham-controlled clinical trial. Clin J Pain. Mar 2014; 30(3): 214-23.
6. Hong CZ. Specific sequential myofascial trigger point therapy in the treatment of a patient with myofascial pain syndrome associated with reflex sympathetic dystrophy. Australas Chiropr Osteopathy. Mar 2000; 9(1): 7-11.
7. IOM (Institute of Medicine). 2011. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press.
8. Kang JJ, Kim J, Park S, Paek S, Kim TH, Kim DK. Feasibility of Ultrasound-Guided Trigger Point Injection in Patients with Myofascial Pain Syndrome. Healthcare (Basel). 2019 Oct 15;7(4):118. 
9. Kumbhare DA, Elzibak AH, Noseworthy MD. Assessment of Myofascial Trigger Points Using Ultrasound. Am J Phys Med Rehabil. 2016 Jan;95(1):72-80.
10. Lugo LH, Garcia HI, Rogers HL, et al. Treatment of myofascial pain syndrome with lidocaine injection and physical therapy, alone or in combination: a single blind, randomized, controlled clinical trial. BMC Musculoskelet Disord. Feb 24 2016; 17: 101.

POLICY HISTORY:

Medical Policy Group, May 2021 (7): New Policy addressing trigger point injections. Information transferred from MP#303. Literature reviewed, no new references added. Added Key Word: "TPIs." No change in coverage. Removed “not medically necessary” statements from Policy Statement; no change in intent.

Medical Policy Panel, April 2022

Medical Policy Group, April 2022 (7): Minor updates to Key Points. No new references added. No change in Policy Statement.

Medical Policy Panel, April 2023

Medical Policy Group, May 2023 (7): Minor updates to Key Points, Benefit Application, and References. No change in Policy Statement.

Medical Policy Group, August 2023 (7): Clarification to investigational statement regarding image guidance to state that imaging in addition to ultrasound is considered investigational- added “and other imaging guidance.” References added. Update to Key Points. No change to intent of Policy Statement.

Medical Policy Panel, April 2024

Medical Policy Group, May 2024 (7): Minor updates to Key Points. No new references added. No change in Policy Statement.

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;
2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;
3. The technology must improve the net health outcome;
4. The technology must be as beneficial as any established alternatives;
5. The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and
2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and
3. Not primarily for the convenience of the patient, physician or other health care provider; and
4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.