**History/Background and/or General Information**

Injection of a tendon sheath, ligament or trigger point consists of an
anesthetic agent and/or steroid agent injected into an area for the management
of pain. This Local Coverage Determination only addresses the injection of
trigger points.

Trigger points are areas of taut muscle bands or palpable knots of the muscle,
that are painful on compression and can produce referred pain, referred
tenderness, and/or motor dysfunction. A trigger point may occur in any
skeletal muscle/fascia in response to strain produced by acute or chronic
overload. Pain from trigger points can be mild to severe. When trigger point
pain is severe and unresponsive to non-invasive treatments (e.g., anti-
inflammatory medications, physical therapy, etc.), trigger point injections
with local anesthetic and/or a steroid agent may be helpful.

Besides injection into trigger points, local injections are useful in the
treatment of pain or dysfunction due to inflammation or other pathological
changes of tendon sheaths, and ligaments. Findings may include pain on motion
or palpation, swelling, friction rubs and/or catches.

**Covered Indications**

The injection of trigger point(s) will be considered to be medically
reasonable and necessary for the treatment of trigger points that are
unresponsive to non-invasive treatments or when non-invasive methods of
treatment are contraindicated. The medical record should clearly reflect all
methods attempted and the results. If treatments are contraindicated, the
medical record should indicate why the trigger point(s) is not amenable to
other therapeutic modalities.

Non-invasive treatments may include, but are not limited to:

  * Medications (non-steroidal anti-inflammatory drugs, muscle relaxants, etc.)
  * Physical therapy (massage, heat or ice, stretching, etc.)
  * Activity modification
  * Home exercise instruction

Repeat trigger point injections may be necessary when there is evidence of
persistent pain or inflammation. Evidence of partial improvements to the range
of motion in any muscle area after an injection would justify a repeat
injection.

It is not recommended that trigger point injections be used on a routine basis
for patients with chronic non-malignant pain syndromes. In addition, several
studies indicated that when additional injections are required in a series,
other therapies (e.g., medications, physical therapy) in addition to the
injections may be beneficial.

**Limitations**

The frequency at which trigger point injection(s) are performed is dependent
on the clinical presentation of the patient. However, it is generally expected
that the patient's response to the previous injection is important in deciding
whether to proceed with additional injections. If the patient has achieved
significant benefit after the first injection, an additional injection would
be appropriate for reoccurring symptoms. (Repeated injections may be justified
by evidence of improvement, such as reduction in pain, muscle tenderness,
spasm; or improvement in the range of motion.)

Multiple trigger points may be injected during any one session. Some trigger
points may need to be re-injected weekly or monthly for brief intervals
consisting of a few months, depending on the results of the injections and the
relief of pain that the injection provides. If therapeutic effect is achieved,
medical literature supports that no more than three sets (or sessions) of
injections should be performed during one year.

If the patient experiences no symptom relief or functional improvement after
two to three injections into a muscle, repeated injections into that muscle
are not recommended.

As published in the CMS IOM Publication 100-08, _Medicare Program Integrity
Manual_ , Chapter 13, Section 13.5.4, an item or service may be covered by a
contractor LCD if it is reasonable and necessary under the Social Security Act
Section 1862 (a)(1)(A). Contractors shall determine and describe the
circumstances under which the item or service is considered reasonable and
necessary.