Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lower back pain. 
Treatment: Pain injection (20553 x 1) (trigger point injections). 
The insurer denied coverage for pain injection (20553 x 1) (trigger point injections). 
The denial is upheld. 

According to the documentation submitted, this is an adult with a history of lower back pain. The patient presented to the Pain Management practitioner's office for a follow up for lower back pain. Pain became worse since the last visit. The patient tried and failed physical therapy (PT), a home exercise program, and medications. The treating practitioner recommended trigger point injections to treat pain. 

Liu et al (1) conducted a systematic review and meta-analysis of trigger point injections in low back pain. They concluded:

"Moderate evidence showed that dry needling of Myofascial trigger points (MTrPs), especially if associated with other therapies, could be recommended to relieve the intensity of lower back pain (LBP) at postintervention; however, the clinical superiority of dry needling in improving functional disability and its follow-up effects still remains unclear."

Similarly, Hu et al (2) conducted another systematic review and found:

"Sixteen Randomized Controlled Trials (RCTs) were included and the risk of bias assessment of them was "high" or "unclear" for most domains. Meta-analysis results suggested that dry needling (DN) was more effective than acupuncture in alleviating pain intensity and functional disability at postintervention, while its efficacy on pain and disability at follow-up was only equal to acupuncture. Besides, DN was superior to sham needling for alleviating pain intensity at postintervention/follow-up and functional disability at postintervention. Additionally, qualitative review revealed that DN combined with acupuncture had more significant effect on alleviating pain intensity at postintervention and achieved higher response rate than DN alone. However, compared with other treatments (laser, physical therapy, other combined treatments, etc.), it remained uncertain whether the efficacy of DN was superior or equal because the results of included studies were mixed".

They concluded:

"Compared with acupuncture and sham needling, DN is more effective for alleviating pain and disability at postintervention in LBP, while its effectiveness on pain and disability at follow-up was equal to acupuncture. Besides, it remains uncertain whether the efficacy of DN is superior to other treatments. Nevertheless, considering the overall "high" or "unclear" risk of bias of studies, all current evidence is not robust to draw a firm conclusion regarding the efficacy and safety of DN for LBP. Future RCTs with rigorous methodologies are required to confirm our findings."

The lack of documentation of taut bands and pain referral patterns are necessary to clearly identify trigger points. Absent this documentation, the request is deemed not medically reasonable and necessary.  

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for pain injection (20553 x 1) is not substantiated.