Clinical UM Guideline

 

Subject: Trigger Point Injections
Guideline #:  CG-SURG-17 Publish Date:    06/06/2018
Status: Reviewed Last Review Date:    05/03/2018

Description

This document addresses trigger point injections and dry needling trigger point stimulation.

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:

I. 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:

  1. General Criteria
    1. There is a regional pain complaint; and
    2. 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
    3. Conservative therapy (for example, physical or chiropractic therapy, oral analgesia, steroids, relaxants or activity modification) fails or is not feasible; and
    4. When necessary to facilitate mobilization and return to activities of daily living, an aggressive regimen of physical therapy or other therapeutic modalities; and
    5. The response to therapy must be documented for medical review prior to additional therapy authorizations.
  2. Specific Criteria
    1. Pain complaint or altered sensation in the expected distribution of referred pain from a trigger point; and
    2. Taut band palpable in an accessible muscle when the trigger point is myofascial; and
    3. Exquisite spot tenderness at one point along the length of the taut band when the pain is myofascial; and
    4. Some degree of restricted range of motion of the involved muscle or joint, when measurable; and
    5. The above specific criteria are associated with at least ONE of the following MINOR CRITERIA:
      1. Reproduction of clinical pain complaint or altered sensation by pressure on the tender spot; or
      2. Local response (twitch) elicited by snapping palpation at the tender spot or by needle insertion into the tender spot; or
      3. Pain alleviation by elongating (stretching) the muscle or by injecting the tender spot.

II. 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 (ACR) diagnostic criteria for fibromyalgia or the ACR Preliminary Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity criteria are met.

  1. Based on the 1990 ACR diagnostic criteria for fibromyalgia, the following criteria must be met:
    1. 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; and
    2. Pain, on digital palpation, must be present in at least 11 of the following 18 sites:
      1. Occiput: bilateral, at the suboccipital muscle insertions;
      2. Low cervical: bilateral, at the anterior aspects of the intertransverse spaces at C5-C7;
      3. Trapezius: bilateral, at the midpoint of the upper border;
      4. Supraspinatus: bilateral, at origins, above the scapula spine near the medial border;
      5. Second rib: bilateral, at the second costochondral junctions, just lateral to the junctions on upper surfaces;
      6. Lateral epicondyle: bilateral, 2 cm distal to the epicondyles;
      7. Gluteal: bilateral, in upper outer quadrants of buttocks in anterior fold of muscle;
      8. Greater trochanter: bilateral, posterior to the trochanteric prominence;
      9. Knee: bilateral, at the medial fat pad proximal to the joint line.
        or
  2. Based on the 2010 ACR Preliminary Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity guidelines, the following criteria must be met:
    1. The widespread pain index (WPI) scale score is:
      1. greater than or equal to 7 and the symptom severity (SS) scale score is greater than or equal to 5; or
      2. the WPI scale score is 3-6 and the SS scale score is greater than or equal to 9; and
    2. The individual’s symptoms have been present at a similar level for a minimum of three (3) months;
      and
    3. The individual does not have a disorder that would otherwise explain the pain.

WPI Scale Score:
The WPI score is determined by noting the number of areas in which the individual has had pain during the last week (the total number of areas in which the individual has had pain). The cumulative score will be between 0 and 19.

Left shoulder girdle     Right lower arm                             Left lower leg      Abdomen   
Right should girdle      Left hip (buttock, trochanter)      Right lower leg    Upper back
Left upper arm             Right hip (buttock, trochanter)    Left jaw                Lower back
Right upper arm           Left upper leg                                Right jaw              Neck
Left lower arm              Right upper leg                              Chest

SSI Scale Score:
The SS scale score is the sum total of the severity of the 3 symptoms (fatigue, feeling unrefreshed upon awaking and symptoms involving cognition) in addition to the extent (severity) of somatic symptoms in general. The final score will range from 0 to 12.

For each of the 3 symptoms (fatigue, feeling unrefreshed upon awaking and symptoms involving cognition), indicate the level of severity over the past week using the following scale:
0   No problem
1   Slight or mild problems, generally mild or sporadic
2   Moderate, considerable problems, frequently present and/or at a moderate level
3   Severe: pervasive, constant, life-disturbing problems

Giving consideration to somatic symptoms in general, indicate whether the individual has:*
0   No symptoms
1   A few symptoms
2   A moderate number of symptoms
3   A great number of symptoms

*Somatic symptoms may include any of the following: irritable bowel syndrome, muscle pain, fatigue/tiredness, thinking or remembering problem, muscle weakness, headache, pain/cramps in the abdomen, dizziness, numbness/tingling, insomnia, depression, constipation, pain in the upper abdomen, nausea, nervousness, chest pain, blurred vision, fever, diarrhea, itching, wheezing, dry mouth, Raynaud’s phenomenon, hives/welts, ringing in ears, vomiting, heartburn, oral ulcers, loss of/change in taste, seizures, dry eyes, loss of appetite, shortness of breath, rash, sun sensitivity, hearing difficulties, easy bruising, hair loss, frequent urination, painful urination, and bladder spasms.

III. The following schedule for trigger point injections is considered medically necessary when the previous criteria are met:

  1. 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.
  2. 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.
  3. 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:

  1. Trigger point injections are considered not medically necessary in the presence of:
    1. Systemic infections; or
    2. Bleeding tendencies (including individuals undergoing anticoagulation therapy); or
    3. Other concomitant unstable medical conditions.
  2. “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. 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

 

20552

Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)

20553

Injection(s); single or multiple trigger point(s), 3 or more muscles

20999

Unlisted procedure, musculoskeletal system, general [when specified as dry needling]

 

 

ICD-10 Diagnosis

 

 

All diagnoses

Discussion/General Information

A 1990 guideline produced by the American College of Rheumatology (ACR) based the diagnosis of fibromyalgia on the physical examination (presence of at least 11 of 18 specified tender points) and the presence of widespread pain (axial, left and right-sided pain, as well as upper and lower segment). Several objections to these criteria appeared over time. These included the fact that most physicians do not perform technically correct tender point examinations. Researchers discovered that symptoms not considered in the 1990 guideline are consistently associated with the syndrome. In 2010, the ACR published the Preliminary Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity diagnostic criteria which do not require a physical or tender point examination.

A component of the 2010 criteria is the fibromyalgia symptom severity (SS) scale which permits the evaluation of the severity of fibromyalgia symptom in individuals with current or previous fibromyalgia, and in those to whom the criteria have not been applied. It is considered to be especially useful in the longitudinal evaluation of individuals with marked symptom variability (Wolfe, 1990; Wolfe, 2010).

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 (for example, 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 individuals 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 visual analog scales for pain (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, 6 participants (28.6%) received two injections at an interval of 1 week, and 1 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 15 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).

In 2017, De Meulemeester and colleagues reported the results of a randomized controlled trial evaluating 42 individuals with myofascial neck and/or shoulder pain. Study participants were assigned to receive 4 sessions of dry needling (n=20) or manual pressure (n=22). All participants were evaluated with the Neck Disability Index, general numeric rating scale, pressure pain threshold, and muscle characteristics before and after treatment. The primary outcome measure was the Neck Disability Index. All subjects were evaluated after 4 treatments and again after 3 months. There were no significant differences in NDI scores between the dry needling cohort and the manual pressure cohort at either follow-up point (p>0.05).

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.

Brennan and colleagues (2017) reported the results of a randomized and partially blinded trial that investigated if the administration of dry needling is noninferior to cortisone injection in reducing lateral hip pain and improving function in subjects with greater trochanteric pain syndrome (also known greater trochanteric or subgluteal bursitis). A total of 50 individuals, all with greater trochanteric pain syndrome were included in the study. Participants were randomly assigned to receive either cortisone injection (n=25 hips) or dry needling (n=25 hips). Treatments were provided over a period of 6 weeks, and clinical outcomes were assessed at baseline and at 1, 3, and 6 weeks. The primary outcome measure was pain measurement (0-10 rating scale). The secondary and tertiary outcome measures were the Patient-Specific Functional Scale (0-10) and pain medication intake, respectively. Baseline characteristics were similar for both groups. A noninferiority test for a repeated-measures design for pain and averaged function scores at 6 weeks (with a noninferiority margin of 1.5 for both outcomes) suggested that dry needling was noninferior to cortisone injection (both, P<.01). Medication usage (P = .74) was similar between groups at the same time point. The authors concluded that dry needling is a noninferior treatment alternative to cortisone injections in individuals with greater trochanteric pain syndrome. Limitations of this study include but are not necessarily limited to the lack of a sham control group and its small size. 

References

Peer Reviewed Publications:

  1. Alvarez DJ, Rockwell PG. Trigger points: diagnosis and management. Am Fam Physician. 2002; 15; 65(4):653-660.
  2. 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. 2017; 47(4):232-239.
  3. 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.
  4. De Meulemeester KE, Castelein B, Coppieters I, et al. Comparing trigger point dry needling and manual pressure technique for the management of myofascial neck/shoulder pain: a randomized clinical trial. J Manipulative Physiol Ther. 2017; 40(1):11-20.
  5. Huguenin L. Myofascial trigger points: the current evidence. Physical Therapy in Sport 5. 2004; 2-12.
  6. 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.
  7. 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.
  8. Karakurum B, Karaalin O, Coskun O, et al. The 'dry-needle technique': intramuscular stimulation in tension-type headache. 2001; 21(8):813-817.
  9. 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. 2013; 94(5):930-936.
  10. 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, Clauw DJ, Fitzcharles MA, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken). 2010; 62(5):600-610.
  9. 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

Status

Date

Action

Reviewed

05/03/2018

Medical Policy & Technology Assessment Committee (MPTAC) review. The document header wording updated from “Current Effective Date” to “Publish Date.” Updated review date, Rationale, References and History sections.

Revised

05/04/2017

MPTAC review. Updated formatting in the Clinical Indications section. In the Not Medically Necessary statement, inserted the word “or” after bullets IA and IB. Updated review date, Coding, and History sections.

Reviewed

05/5/2016

MPTAC review. Updated review date, References and History sections.

 

01/01/2016

Updated Coding section with 01/01/2016 descriptor change for CPT 20553; removed ICD-9 codes.

Revised

05/07/2015

MPTAC review. Expanded the medically necessary criteria for trigger point injections for individuals with fibromyalgia to include the 2010 ACR criteria. Updated review date, Discussion/General Information, References and History sections.

Reviewed

05/15/2014

MPTAC review. Updated References section.

Reviewed

05/09/2013

MPTAC review. Updated Discussion/General Information and References sections.

Reviewed

05/10/2012

MPTAC review. Discussion and References sections updated.

Reviewed

05/19/2011

MPTAC review. References and Coding sections updated.

Reviewed

05/13/2010

MPTAC review. References section updated.

Reviewed

05/21/2009

MPTAC review. Discussion and References sections updated. Place of service removed.

Reviewed

05/15/2008

MPTAC review. References section updated.

Revised

05/17/2007

MPTAC review. Guideline revised to address dry needling. Background, Coding, and References section updated.

Reviewed

12/07/2006

MPTAC review. References section updated.

Revised

12/01/2005

MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.

Pre-Merger Organizations

Last Review Date

Document Number

Title

Anthem, Inc.

 

 

None

Anthem BCBS

 

 

None

WellPoint Health Networks, Inc.

12/02/2004

Guideline

Regional Anesthesia/Pain Management for Chronic Neck, Back and Myofascial Pain