**Abstract:**  
  
Acute pain is elicited by the injury of body tissues and activation of
nociceptive transducers at the site of local tissue damage. This type of pain
is often a reason to seek health care, and it occurs after trauma, surgical
interventions, and some disease processes.  
  
Chronic pain has been defined as "persistent or episodic pain of duration or
intensity that adversely affects the function or well-being of the patient,
attributable to any nonmalignant etiology" ("Practice Guidelines for Chronic
Pain Management: A Report by the American Society of Anesthesiologists Task
Force on Pain Management, Chronic Pain Section"). In addition, the pain has
been refractory to repeated attempts at medical management and usually has
been present for at least three to six months.  
  
Pain associated with cancer includes pain associated with disease progression
as well as treatments. Pain associated with cancer can have multiple causes--
namely, disease progression, treatment (e.g., neuropathic pain resulting from
radiation therapy), and co-occurring diseases (e.g., arthritis). Regardless of
whether the pain associated with cancer stems from disease progression,
treatment, or a co-occurring disease, it may be either acute or chronic.  
  
Spinal pain generates from multiple structures in the spine. Certain
conditions may not be detectable using currently available technology or
biochemical studies. However, for a structure to be implicated, it should have
been shown to be a source of pain in patients, using diagnostic techniques of
known reliability and validity. The structures responsible for pain in the
spine, include but are not limited to, the vertebral bodies, intervertebral
discs, spinal cord, nerve roots, facet joints, ligaments, muscles, atlanto-
occipital joints and atlanto-axial joints.  
  
Postlaminectomy syndrome/failed back syndrome or pain following operative
procedures of the spine, sometimes known as failed management syndrome, is
becoming an increasingly common entity in modern medicine. Other spinal
conditions causing pain include various degenerative disorders such as spinal
stenosis, spondylolysis, spondylolisthesis, degenerative scoliosis, idiopathic
vertebrogenic sclerosis, diffuse idiopathic spinal hyperostosis, and segmental
instability. Degenerative conditions other than disc disruption and facet
arthritis may contribute to approximately 5% to 10% of spinal pain.  
  
Neural blockade is one technique used in chronic pain management. Neural
blockade is the interruption of neural transmission by the injection of a
local anesthetic agent or other drug. Nerve block therapy can be used to
answer specific questions resulting from a careful evaluation of the patient's
pain problem and to gain insight into the underlying problem causing the pain.
Success of the nerve block is determined by the adequacy of interruption of
nerve function, and the effect of that blockade on the patient's pain. The
goal of chronic pain management is to achieve optimal pain control,
recognizing that a pain-free state may not be achievable; minimize adverse
outcomes; enhance functional abilities and physical and psychological well-
being; and enhance the quality of life for patients with chronic pain.  
  
The decision to treat chronic pain by invasive or destructive procedures must
be based on a thorough evaluation of the patient and include a systematic
assessment of the location, intensity, and pathophysiology of the pain. A
detailed pain history that includes prior treatment and response to treatment
is essential. A detailed physical examination and review of all pertinent
diagnostic tests is also needed. This local coverage determination documents
National Government Services indications and limitations for pain management
treatment.  
  
For complete coverage detail, please review each of the following sections:
Indications and Limitations for Specific Types of Injections, Limitations for
All Diagnostic and Therapeutic Pain Management Services. Documentation
Requirements and Utilization Guidelines have been moved to Coding and Billing
article A52863.  
  
  
 **Indications and Limitations for Specific Types of Injections  
  
TRIGGER POINT INJECTIONS**  
  
Trigger point injection is one of the many modalities utilized in the
management of chronic pain. Myofascial trigger points are self-sustaining
hyperirritative 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. Production of
a referred pain pattern differentiates myofascial pain syndrome from tender
points and fibromyalgia. Each pattern becomes part of a single muscle
myofascial pain syndrome (MPS); and each of these single muscle syndromes is
responsive to appropriate treatment, which includes injection therapy.
Injection is achieved with needle insertion and the administration of agents
such as local anesthetics.  
  
 **Indications:**  
  
The diagnosis of trigger points requires a detailed history and thorough
physical examination. The following clinical features are present most
consistently, and are helpful in making the diagnosis:  
  

  * History of onset of the painful condition, and its presumed cause (injury, sprain, etc.);
  * Distribution pattern of pain consistent with the referral pattern of the trigger points;
  * Restriction of range of motion with increased sensitivity to stretch;
  * Muscular deconditioning in the affected area;
  * Focal tenderness of a trigger point;
  * Palpable taut band of muscle in which trigger point is located;
  * Local taut response to snapping palpation or needle insertion; and
  * Reproduction of referred pain pattern upon stimulation of the trigger point.

The goal is to treat the cause of the pain and not just the symptom of pain.
Other treatment modalities include:  
  

  * Pharmacologic treatment including analgesics and medications to induce sleep and relax muscles (i.e. antidepressants, neuroleptics, or non steroidal anti-inflammatory drugs); and
  * Nonpharmacologic treatment modalities (i.e., osteopathic manual medicine techniques, massage, ultrasonography, application of heat or ice, transcutaneous electrical nerve stimulation, Spray and Stretch technique); and
  * For trigger points in the acute state of formation (before additional pathologic changes develop), effective treatment may be delivered through physical therapy.

After myofascial pain syndrome is established as described above, trigger
point injection may be indicated when noninvasive medical management is not
successful or as first line treatment. Additionally, trigger point injection
is indicated when the movement of a joint is mechanically blocked as is the
case of the coccygeus muscle.  
  
 **Limitations:**  
  
Only one trigger point injection procedure should be reported on any
particular day, no matter how many sites or regions are injected.  
  
The local anesthetic administered in conjunction with trigger point injections
is included in the practice expense for these procedures.  
  
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.  
  
Only injections of local anesthetics and corticosteroids are covered.
Injections consisting of only saline and/or botanical substances are not
supported in the peer-reviewed literature and are not considered medically
necessary. Prior to January 21, 2020, dry needling is not a covered service.
Effective January 21, 2020, Medicare will cover all types of acupuncture
including dry needling for chronic low back pain within specific guidelines in
accordance with NCD 30.3.3.  
  
  
  
 **INJECTION OF TENDON SHEATHS, LIGAMENTS, GANGLION CYSTS, CARPAL AND TARSAL
TUNNELS**  
  
Injection into tendon sheaths, ligaments, ganglion cysts, tarsal or carpal
tunnel is sometimes indicated to provide relief of pain and to reduce the
inflammation in these structures when response to conservative measures has
failed or is not indicated.  
  
For the purposes of clarity the following descriptions are offered for each
term:  
  
 **Ligament** \- A band of tissue that connects bones.  
  
**Tendon** \- A fibrous cord of connective tissue attaching a muscle to a bone
or other structure. A tendon sheath is the lining enclosing a tendon. It
facilitates movement around the tendon.  
  
**Ganglion cyst** \- These knot like masses are non-cancerous and fluid filled
cysts that arise from the ligaments, joint linings, or tendon sheaths.  
  
 **Carpal tunnel** \- This is a passageway that runs from the forearm through
the wrist. The median nerve and nine tendons pass through the tunnel.  
  
 **Tarsal tunnel** \- A passageway on the medial side of the tarsus. The
posterior tibial nerve passes through the tunnel.  
  
 **Indications for Tendon Sheath, Ligament, Ganglion Cysts, Carpal and Tarsal
Tunnel Injections:**  
  
Injection into tendon sheaths, their origins or insertions, ligaments, or
ganglion cysts is indicated to relieve substantial pain and/or significant
functional disability that results from inflammation or other pathological
changes in those structures. Proper use of this modality should be part of an
overall management plan including diagnostic evaluation in order to clearly
identify and properly treat the primary cause.  
  
Other conservative therapy has not provided acceptable relief, is
contraindicated, or not appropriate.  
  
There is a reasonable likelihood that injection will significantly improve the
patient's pain and/or functional disability.  
  
Injection of a carpal tunnel may be indicated for the patient with mild to
moderate symptoms when pharmaceutical and other conservative measures have
failed or are not otherwise indicated.  
  
Injection of the tarsal tunnel may be indicated for conservative management of
tarsal tunnel syndrome.  
  
**Limitations for Tendon Sheath, Ligament, Ganglion Cysts, Carpal and Tarsal
Tunnel Injections:**  
  
When a given specific tendon, ligament, tunnel, or cyst is injected, it will
be considered one injection service regardless of the number of injections
administered at that specific anatomical location on a single date of service.  
  
**LIMITATIONS FOR ALL PAIN MANAGEMENT SERVICES**  
  
General anesthesia or monitored anesthesia care (MAC) is rarely, if ever
required for injections addressed in this policy. In fact, general anesthesia
is contraindicated for diagnostic blocks (Manchikanti et al, 2005). Further,
monitored anesthesia care or heavy sedation may provide false-positive
results.  
  
 **Provider Qualifications**  
The CMS Manual System, Pub. 100-8, _Program Integrity Manual,_ Chapter 13,
Section 5.1 (http://www.cms.hhs.gov/manuals/downloads/pim83c13.pdf) states
that "reasonable and necessary" services are "ordered and/or furnished by
qualified personnel." 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 spinal pain management procedures 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. (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). A practitioner who works in a hospital or ASC
facility at any time should be credentialed by the facility for any procedure
also performed in an office setting.