Latest Review Date: April 2024

Category:  Surgical                                                              

POLICY:

For dates of service after July 1, 2021:

Dry needling of trigger points for the treatment of myofascial pain is considered investigational.

For dates of service before July 1, 2021:

Dry needling of trigger points (i.e., injections in several trigger points in one sitting) 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.

**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:

Myofascial pain is defined by the presence of trigger points which are discrete, focal, hyperirritable spots within a taut band of skeletal muscle fibers that produce local and/or referred pain when stimulated. Trigger points are likely a result of injury to muscle fibers, but the pathophysiology is not fully defined. Trigger points can be visualized by magnetic resonance imaging and elastography. The reliability of manual identification of trigger points has not been established.Dry needling refers to a procedure in which a fine needle is inserted into the skin and muscle at a site of myofascial pain. The needle may be moved in an up-and-down motion, rotated, and/or left in place for as long as 30 minutes. The intent is to stimulate underlying myofascial trigger points, muscles, and connective tissues to manage myofascial pain. Dry needling may be performed with acupuncture needles or standard hypodermic needles but is performed without the injection of medications (e.g., anesthetics, corticosteroids). Dry needling is proposed to treat dysfunctions in skeletal muscle, fascia, and connective tissue; diminish persistent peripheral pain, and reduce impairments of body structure and function. The physiologic basis for dry needling depends on the targeted tissue and treatment objectives. The most studied targets are trigger points.

Deep dry needling is believed to inactivate trigger points by eliciting contraction and subsequent relaxation of the taut band via a spinal cord reflex. This local twitch response is defined as a transient visible or palpable contraction or dimpling of the muscle, and has been associated with alleviation of spontaneous electrical activity; reduction of numerous nociceptive, inflammatory, and immune system-related chemicals; and relaxation of the taut band. Deep dry needling of trigger points is believed to reduce local and referred pain, improve range of motion, and decrease trigger point irritability. Trigger points are discrete, focal, hyperirritable spots within a taut band of skeletal muscle fibers that produce local and/or referred pain when stimulated.

Superficial dry needling is thought to activate mechanoreceptors and have an indirect effect on pain by inhibiting C-fiber pain impulses. The physiologic basis for dry needling treatment of excessive muscle tension, scar tissue, fascia, and connective tissues is not as well described in the literature.

Note: Trigger point injections are addressed separately in medical policy, #739 Trigger Point Injections.

KEY POINTS:

This policy has been updated regularly with searches of the MEDLINE database. The most recent literature update was performed through February 8, 2024.

Summary of Evidence

For individuals who have myofascial trigger points associated with neck and/or shoulder pain who receive dry needling of trigger points, the evidence includes randomized controlled trials (RCTs) and systematic reviews. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. A second systematic review of techniques to treat myofascial pain included 15 studies of dry needling for neck or shoulder pain published through 2017. Studies had multiple methodological limitations, and the reviewers concluded that the evidence for dry needling was not greater than placebo. In more recent systematic reviews and meta-analyses, dry needling was not associated with clinically important reductions in shoulder or neck pain when compared to other physical therapy modalities. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have myofascial trigger points associated with plantar heel pain who receive dry needling of trigger points, the evidence includes a systematic review of randomized trials. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. The systematic review included 6 randomized trials enrolling 395 patients and found no overall difference in pain intensity in those treated with dry needling compared with active control, placebo, or no intervention. However, pain intensity after at least 3 sessions, long-term pain intensity, and pain-related disability were improved. The systematic review rated the evidence as low to moderate. The evidence for dry needling in patients with plantar heel pain is limited by small patient populations and lack of blinding; therefore, additional, good methodological quality RCTs are needed to strengthen the evidence base. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have myofascial trigger points associated with temporomandibular myofascial pain who receive dry needling of trigger points, the evidence includes 2 RCTs. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment related morbidity. One double-blind, sham-controlled randomized trial was identified; it found that one week after completing the intervention, there were no statistically significant differences between groups in pain scores or function (unassisted jaw opening without pain). There was a significantly higher pain pressure threshold in the treatment group. The second RCT (N = 50) compared dry needling to manual therapy. Both groups experienced improvements from baseline to the end of the study but there was no difference between groups in pain intensity, maximal mouth opening, or disability (using the Neck Disability Index). Methodological quality was limited by a lack of blinding and no reporting of power/sample size calculation. Additional RCTs, especially those with a sham-control group, are needed. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Practice Guidelines and Position Statements

Agency for Healthcare Research and Quality (AHRQ)

In 2009, the American Academy of Orthopaedic Physical Therapists issued a statement that dry needling fell within the scope of physical therapist practice. In support of this position, the Academy stated that “dry needling is a neurophysiological evidence based treatment technique that requires effective manual assessment of the neuromuscular system…. Research supports that dry needling improves pain control, reduces muscle tension, normalizes biochemical and electrical dysfunction of motor endplates, and facilitates an accelerated return to active rehabilitation.”

American Physical Therapy Association

In 2012, an educational resource paper by the American Physical Therapy Association defined dry needling as “a skilled intervention used by physical therapists (where allowed by state law) that uses a thin filiform needle to penetrate the skin and stimulate underlying myofascial trigger points, muscular, and connective tissues for the management of neuromusculoskeletal pain and movement impairments.” In 2013, the Association issued an educational resource paper that included the following indications for dry needling: radiculopathies, joint dysfunction, disc pathology, tendonitis, craniomandibular dysfunction, carpal tunnel syndrome, whiplash-associated disorders, and complex regional pain syndrome.

In 2023, the American Physical Therapy Association published an updated guideline on nonarthritic heel pain (plantar fasciitis).

The guideline stated that dry needling of myofascial trigger points in the following areas should be used: gastrocnemius, soles, and plantar muscles of the foot. The evidence supports the efficacy of this technique for pain and long-term function and improved disability, especially in patients with chronic heel pain (defined as lasting more than 1 month). The recommendation was based in part on the systematic review conducted by Llurda-Almuzara discussed above, and more recent studies with methodological limitations including lack of a sham control comparison group.

U.S Preventive Services Task Force Recommendations

Not applicable.

KEY WORDS:

Dry needling, myofascial pain, trigger points

APPROVED BY GOVERNING BODIES:

Dry needling is considered a procedure and, as such, is not subject to regulation by the U.S. Food and Drug Administration.

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. Alvarez DJ, Rockwell PG. Trigger points: diagnosis and management. Am Fam Physician. Feb 15 2002; 65(4): 653-60.
2. American Academy of Orthopaedic Physical Therapists. AAOMPT position statement on dry needling. 2009; http://aaompt.org/Main/About_Us/Position_Statements/Main/About_Us/Position_Statements.aspx?hkey=03f5a33 3-f28d-4715-b355-cb25fa9bac2c.
3. American Physical Therapy Association (APTA). Dry Needling. n.d.; https://www.apta.org/patient-care/interventions/dryneedling.
4. American Physical Therapy Association (APTA). Physical Therapists and the Performance of Dry Needling. 2012; http://www.apta.org/StateIssues/DryNeedling/ResourcePaper/.
5. Bagcier F, Yilmaz N. The Impact of Extracorporeal Shock Wave Therapy and Dry Needling Combination on Pain and Functionality in the Patients Diagnosed with Plantar

6. Fasciitis. J Foot Ankle Surg. Jul 2020; 59(4): 689-693.

7. Bernstein CD, Yonter S, Pradeep A, Shah JP, Weiner DK. Fibromyalgia and Myofascial Pain Syndromes. In: Halter JB, Ouslander JG,Studenski S, High KP, Asthana S, Supiano MA, Ritchie CS, Schmader K. eds. Hazzard's Geriatric Medicine and Gerontology, 8e.McGraw Hill; 2022.
8. Brady S, McEvoy J, Dommerholt J, et al. Adverse events following trigger point dry needling: a prospective survey of chartered physiotherapists. J Man Manip Ther. Aug 2014; 22(3): 134-40.
9. Charles D, Hudgins T, MacNaughton J, et al. A systematic review of manual therapy techniques, dry cupping and dry needling in the reduction of myofascial pain and myofascial trigger points. J Bodyw Mov Ther. Jul 2019; 23(3): 539-546.
10. Cotchett MP, Munteanu SE, Landorf KB. Effectiveness of trigger point dry needling for plantar heel pain: a randomized controlled trial. Phys Ther. Aug 2014; 94(8): 1083-94.
11. Cotchett MP, Landorf KB, Munteanu SE. Effectiveness of dry needling and injections of myofascial trigger points associated with plantar heel pain: a systematic review. J Foot Ankle Res. Sep 01 2010; 3: 18.
12. Diracoglu D, Vural M, Karan A, et al. Effectiveness of dry needling for the treatment of temporomandibular myofascial pain: a double-blind, randomized, placebo controlled study. J Back Musculoskelet Rehabil. 2012; 25(4): 285-90.
13. Eftekharsadat B, Babaei-Ghazani A, Zeinolabedinzadeh V. Dry needling in patients with chronic heel pain due to plantar fasciitis: A single-blinded randomized clinical trial. Med J Islam Repub Iran. 2016; 30: 401.
14. García-de la-Banda-García R, Cortés-Pérez I, Ibancos-Losada MDR, et al. Effectiveness of Dry Needling versus Manual Therapy inMyofascial Temporomandibular Disorders: A Single-Blind Randomized Controlled Trial. J Pers Med. Sep 21 2023; 13(9).
15. IOM (Institute of Medicine). 2011. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press.
16. Koc TA, Bise CG, Neville C, et al. Heel Pain - Plantar Fasciitis: Revision 2023. J Orthop Sports Phys Ther. Dec 2023; 53(12): CPG1-CPG39.
17. Llurda-Almuzara L, Labata-Lezaun N, Meca-Rivera T, et al. Is Dry Needling Effective for the Management of Plantar Heel Pain or Plantar Fasciitis? An Updated Systematic Review and Meta-Analysis. Pain Med. Jul 25 2021; 22(7): 1630-1641.
18. Navarro-Santana MJ, Gomez-Chiguano GF, Cleland JA, et al. Effects of Trigger Point Dry Needling for Nontraumatic Shoulder Pain of Musculoskeletal Origin: A Systematic Review and Meta-Analysis. Phys Ther. Feb 04 2021; 101(2).
19. Navarro-Santana MJ, Sanchez-Infante J, Fernandez-de-Las-Penas C, et al. Effectiveness of Dry Needling for Myofascial Trigger Points Associated with Neck Pain Symptoms: An Updated Systematic Review and Meta-Analysis. J Clin Med. Oct 14 2020; 9(10).
20. Para-García G, García-Muñoz AM, López-Gil JF, et al. Dry Needling Alone or in Combination with Exercise Therapy versus Other Interventions for Reducing Pain and Disability in Subacromial Pain Syndrome: A Systematic Review and Meta-Analysis. Int J EnvironRes Public Health. Sep 02 2022; 19(17).
21. Rahbar M, Kargar A, Eslamian F, Dolatkhah N. Comparing the efficacy of dry needling and extracorporeal shock wave therapy in treatment of plantar fasciitis. J Mazandaran Univ Med Sci. 2018;28(164):53-62.
22. Rastegar S, Baradaran Mahdavi S, Hoseinzadeh B, et al. Comparison of dry needling and steroid injection in the treatment of plantar fasciitis: a single-blind randomized clinical

23. trial. Int Orthop. Jan 2018; 42(1): 109-116.

24. Uygur E, Aktas B, Eceviz E, et al. Preliminary Report on the Role of Dry Needling Versus Corticosteroid Injection, an Effective Treatment Method for Plantar Fasciitis: A Randomized Controlled Trial. J Foot Ankle Surg. Mar 2019; 58(2): 301-305.

POLICY HISTORY:

Medical Policy Group, May 2021 (7): New Policy addressing dry needling of trigger points. Information transferred from MP#303. Updates to Key Points and References. Policy statement updated: Dry needling of trigger points is considered investigational and noncovered.  Available for comment May  14, 2021 through June 30, 2021.

Medical Policy Panel, April 2022

Medical Policy Group, April 2022 (7): Updates to Key Points and References. No change in Policy Statement.

Medical Policy Panel, April 2023

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

Medical Policy Panel, April 2024

Medical Policy Group, April 2024 (7): Updates to Key Points and References. 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.