Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The Appeal Number is:
1-10165312542
The rules state that Myofascial trigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic overload. These trigger points produce a referred pain pattern characteristic for that individual muscle. Each pattern becomes part of a single muscle myofascial pain syndrome (MPS); each of these single muscle syndromes is responsive to appropriate treatment. To successfully treat chronic myofascial pain syndrome, each single muscle syndrome needs to be identified along with every perpetuating factor. There is no laboratory or imaging test for establishing the diagnosis of trigger points; it depends therefore, upon the detailed history and thorough directed examination. The following clinical features are present most consistently and are helpful in making the diagnosis:
1. history of onset and its cause (injury, sprain, etc.);
2. distribution of pain;
3. restriction of movement;
4. mild muscle specific weakness;
5. focal tenderness of a trigger point;
6. palpable taut band of muscle in which trigger point is located;
7. local taut response to snapping palpitation; and
8. reproduction of referred pain pattern upon most sustained mechanical stimulation of the trigger point.
The goal is to identify and treat the cause of the pain and not just the symptom of pain. After making the diagnosis of myofascial pain syndrome and identifying the trigger point responsible for it, the treatment options are:
1. medical management, including the use of anti-inflammatory agents, tricyclics, etc.;
2. stretch and use of coolant spray followed by hot packs and/or aerobic exercises;
3. application of low intensity ultrasound directed at the trigger point (this approach is used when the trigger point is otherwise inaccessible);
4. deep muscle massage;
5. injection of local anesthetic into the muscle trigger points:
a. as the initial or the only therapy when a joint movement is mechanically blocked, as is the case of coccygeus muscle, or when a muscle cannot be stretched fully, as is the case of the lateral pterygoid muscle;
b. as treatment of trigger points that are unresponsive to non-invasive methods of treatment, e.g., use of medications, stretch and spray.
NOTE: For all conditions, the actual area must be reported specifically and must be documented in the medical record. Using a non-specific diagnosis code to support injections of multiple areas of the body, rather than more specific diagnosis codes, may result in denial of payment.
1. Known trigger points may be treated at frequencies necessitated by the nature and the severity of associated symptoms and signs
2. Per national Medicare regulations acupuncture is not a covered service, even if provided for treatment of established trigger point:
a. Use of acupuncture needles and/or the passage of electrical current through these needles is not a covered service whether the service is rendered by an acupuncturist or any other provider;
b. providers of acupuncture services should inform the beneficiary that such services will not be covered; and
c. prolotherapy is not covered by Medicare and cannot be billed under the trigger point injection code.
3. If the service has been provided for a diagnosis that is not listed in the covered diagnosis codes section, the provider must thoroughly document the medical necessity and rationale for providing the service for the unlisted diagnosis in the patient's medical records and this must be provided at the review level for consideration.
You can find these rules in the Local Coverage Determination (LCD) for Trigger Points, Local Injections, L34588.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.