**Initial Trigger Point Injection**

Trigger point injections (TPI) will be considered medically reasonable and
necessary to treat myofascial pain caused by trigger points when all the
following requirements are met:

  1. There is a focal area of pain in the skeletal muscle.



  2. There is clinical evidence of a trigger point defined as pain in a skeletal muscle that is associated with at least 2 of the following findings: the presence of a hyperirritable spot and/or taut band identified by palpation and possible referred pain **AND**



  3. The physical examination identifies a focal hypersensitive bundle or nodule of muscle fiber harder than normal consistency with or without a local twitch response and referred pain **AND**



  4. Non-invasive conservative therapy is not successful as first line treatment **OR** movement of a joint or limb is limited or blocked **OR** the TPI is necessary for diagnostic confirmation.

**Subsequent TPI**

Repeat Trigger point injections in previously injected trigger points will be
considered medically reasonable and necessary to treat myofascial pain
syndrome when all the following requirements are met:

  1. There is a positive pain response from the most recent TPI defined as providing consistent minimum of 50% relief of primary (index) pain after the TPI measured by the SAME pain scale* at baseline and post-injection **AND**
  2. Consistent pain relief from the most recent previous TPI lasting at least 6 weeks1  **AND**
  3. The myofascial pain has reoccurred and is causing objective functional limitations measured by a functional scale obtained at baseline and after TPI which demonstrated at least 50% improvement from the previous TPI.

*Note: The scales used to measure pain and/or disability must be documented in the medical record. Acceptable scales include but are not limited to: verbal rating scales, Numerical Rating Scale (NRS) and Visual Analog Scale (VAS) for pain assessment, and Pain Disability Assessment Scale (PDAS), Oswestry Disability Index (ODI), Oswestry Low Back Pain Disability Questionnaire (OSW), Quebec Back Pain Disability Scale (QUE), Roland Morris Pain Scale, Back Pain Functional Scale (BPFS), and the PROMIS profile domains to assess function.

Limitations: No more than three (3) TPI sessions will be reimbursed per
rolling 12 months.

**Requirements:**

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  1. Patients should be part of an ongoing conservative treatment program and documentation to support the patient is actively participating in a rehabilitation program, home exercise program or functional restoration program is in the medical record.

  2. There should be at least 6 weeks duration before TPI is repeated in the same location.  
  

  3. Trigger point primary index pain must be measured prior to the injection at the beginning of the session.  
  

  4. The post procedure pain level must be measured after the TPI at the conclusion of the session using the same scale* utilized at baseline.  
  

  5. When documenting the percentage of pain relief from the primary (index) pain compared to the post-injection pain levels, it is insufficient to report only a percentage of pain relief and/or a nonspecific statement of the duration of pain relief. The documentation should include a specific assessment of the duration of relief being consistent or inconsistent with the agent used for the injection and the specific dates the measurements were obtained using the SAME pain scale* used at baseline.  
  

  6. When documenting the ability to perform previously painful movements and activities of daily living (ADLs) it is insufficient to provide a vague or nonspecific statement regarding the improvement of previously painful movements and activities of daily living (ADLs). The documentation should include a functional assessment to show clinically meaningful improvement with painful movements and ADLs, if this metric is used to justify the efficacy of the TPI Providers should use established and measurable goals and objective scales to assess functionality and ADLs measures.

****

**Limitations:**

  1. A TPI involves the use of a local anesthetic and does not include injections of biologics (e.g., platelet rich plasma, stem cells, amniotic fluid, etc.) and/or any other injectates.  
  

  2. It is not considered medically reasonable and necessary to perform TPI into multiple muscle groups in different anatomical regions during the same session.  
  

  3. It is not considered medically reasonable and necessary to perform multiple blocks (ESI, sympathetic blocks, facet blocks etc.) during the same session as TPI.  
  

  4. Trigger points injections for treatment of headache, neck pain or low back pain in absence of actual trigger points, diffuse muscle pain, a chronic pain syndrome, lumbosacral canal stenosis, fibromyalgia, non-malignant multifocal musculoskeletal pain, complex regional pain syndrome, sexual dysfunction/ pelvic pain, whiplash, neuropathic pain, and hemiplegic shoulder pain ** __** are considered investigational and therefore are not considered medically reasonable and necessary.
  5. Use of fluoroscopy or MRI guidance for performance of TPI is not considered reasonable and necessary.
  6. The use of ultrasound guidance for the performance of TPI is considered investigational.
  7. Trigger point injections used on a routine basis, e.g., on a regular periodic and continuous basis, for patients with chronic non-malignant pain syndromes are not considered medically necessary.

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**Provider Qualifications:**

The Medicare Program Integrity Manual states services will be considered
medically reasonable and necessary only if performed by appropriately trained
providers.

Patient safety and quality of care mandate that healthcare professionals who
perform TPI injections/procedures for chronic pain (not surgical anesthesia)
are appropriately trained and/or credentialed by a formal residency/fellowship
program and/or are certified by either an accredited and nationally recognized
organization or by a post-graduate training course accredited by an
established national accrediting body or accredited professional training
program whose core curriculum includes the performance and management of the
procedures addressed in this policy. Credentialing or privileges are required
for procedures performed in inpatient and outpatient settings.2

All aspects of care must be within the provider's medical licensure and scope
of practice. Reimbursement for procedures utilizing imaging techniques may be
made to providers who meet training requirements for the procedures in this
policy only if their respective state allows such in their practice act and
formally licenses or certifies the practitioner to use and interpret these
imaging modalities (ionizing radiation and associated contrast material,
magnetic resonance imaging, ultrasound). At a minimum, training must cover and
develop an understanding of anatomy and drug pharmacodynamics and kinetics as
well as proficiency in diagnosis and management of disease, the technical
performance of the procedure, and utilization of the required associated
imaging modalities.



Trigger point injections have been described as an overall safe and effective
modality for the treatment of pain associated with myofascial trigger points.
There is moderate evidence to support the role of trigger point injections for
myofascial pain related to the presence of a trigger point. Nonetheless, there
are no high quality randomized controlled trials or large observational
studies to support this and most studies that have investigated TPI are not
blinded, lack controls, standardized patient selection and assessment of
improvement, have small sample sizes and lack of long-term follow-up.

Evidence suggests that early conservative measures, such as physical therapy,
may prevent the need for injections. Therefore, TPI are covered for refractory
pain associated with trigger points that do not respond to conservative
therapy or in patients with significant limitations in mobility that can be
improved by the trigger point while undergoing conservative treatment.
Additionally, a single diagnostic trigger point can play a role in diagnosis
for myofascial pain and ACNEs. There is evidence to support a role for
treatment of headache if associated with the presence of a trigger point. The
frequency of trigger point injections is not well established in the
literature, but most experts agree that the benefit should last at least 4
weeks and typically several months. There is a paucity of evidence on long
term use of TPI and most literature is limited to 2 to 8 weeks. Use of TPI
beyond 6 months is not supported in current literature.



The use of TPI for other conditions other than myofascial pain including non-
specific low back pain (LBP), complex regional pain syndrome, widespread
diffuse pain, chronic pain syndrome, fibromyalgia, pelvic floor myalgia,
hemiplegic shoulder pain, lumbosacral canal stenosis, whiplash, non-malignant
musculoskeletal pain, and neuropathic pain is not supported by evidence and
therefore considered investigational.



There are some emerging studies that help define the ultrasound
characteristics associated with trigger points and exploring a role of
ultrasound guidance for TPI. However, there is not a clear standard for
characterization of the trigger points and adjacent soft tissue by ultrasound.
There is a paucity of evidence that ultrasound improves effectiveness of TPI
and a lack of evidence that it improves safety. Therefore its use is
considered investigational.