evekhm/cms_iom_500 huggingface dataset:
Proposed LCD - Trigger Point Injections (TPI) (DL34211)
Manchikanti L, Singh V, Kloth D, et al. Interventional techniques in the management of chronic pain: Part 2. Pain Physician 2001;4(1):24Title XVIII of the Social Security Act: Sec. 1861.(s)(2) Part E-Miscellaneous Provisions: Definitions of Services I e. Secondary.https://www.ssa.gov/OP_Home/ssact/title18/1861.htm#ft495.Borg-Stein J, Stein J. Trigger points and tender points: one and the same? Does injection treatment help? Rheum Dis Clin North Am 1996;22(2):305-22 doi: 10.1016/s0889-857x(05)70274-x[published Online First: Epub Date]|.Fernndez-de-Las-Peas C, Dommerholt J. International consensus on diagnostic criteria and clinical considerations of myofascial trigger points: a Delphi study. Pain Medicine 2018;19(1):142-50Alvarez DJ, Rockwell PG. Trigger points: diagnosis and management. American family physician 2002;65(4):653Shankar H, Reddy S. Two-and three-dimensional ultrasound imaging to facilitate detection and targeting of taut bands in myofascial pain syndrome. Pain medicine 2012;13(7):971-75Ball A, Perreault T, Fernndez-de-Las-Peas C, Agnone M, Spennato J. Ultrasound Confirmation of the Multiple Loci Hypothesis of the Myofascial Trigger Point and the Diagnostic Importance of Specificity in the Elicitation of the Local Twitch Response. Diagnostics (Basel) 2022;12(2) doi: 10.3390/diagnostics12020321[published Online First: Epub Date]|.Lewis J, Tehan P. A blinded pilot study investigating the use of diagnostic ultrasound for detecting active myofascial trigger points. Pain 1999;79(1):39-44Rha D-w, Shin JC, Kim Y-K, Jung JH, Kim YU, Lee SC. Detecting local twitch responses of myofascial trigger points in the lower-back muscles using ultrasonography. Archives of physical medicine and rehabilitation 2011;92(10):1576-80. e1
Proposed LCD - Trigger Point Injections (TPI) (DL34211)
Sikdar S, Shah JP, Gebreab T, et al. Novel applications of ultrasound technology to visualize and characterize myofascial trigger points and surrounding soft tissue. Archives of physical medicine and rehabilitation 2009;90(11):1829-38Cojocaru MC, Cojocaru IM, Voiculescu VM, Cojan-Carlea NA, Dumitru VL, Berteanu M. Trigger pointsultrasound and thermal findings. J Med Life 2015;8(3):315-8Kang JJ, Kim J, Park S, Paek S, Kim TH, Kim DK. Feasibility of Ultrasound-Guided Trigger Point Injection in Patients with Myofascial Pain Syndrome. Healthcare (Basel) 2019;7(4) doi: 10.3390/healthcare7040118[published Online First: Epub Date]|.Botwin KP, Sharma K, Saliba R, Patel BC. Ultrasound-guided trigger point injections in the cervicothoracic musculature: a new and unreported technique. Pain Physician 2008;11(6):885-9Quintner JL, Bove GM, Cohen ML. A critical evaluation of the trigger point phenomenon. Rheumatology 2014;54(3):392-99 doi: 10.1093/rheumatology/keu471[published Online First: Epub Date]|.Shipton B, Sagar S, Mall JK. Trigger Point Management. Am Fam Physician 2023;107(2):159-64Ahmed S, Subramaniam S, Sidhu K, et al. Effect of Local Anesthetic Versus Botulinum Toxin-A Injections for Myofascial Pain Disorders: A Systematic Review and Meta-Analysis. Clin J Pain 2019;35(4):353-67 doi: 10.1097/AJP.0000000000000681[published Online First: Epub Date]|.
Proposed LCD - Trigger Point Injections (TPI) (DL34211)
Nouged E, Dajani J, Ku B, Al-Eryani K, Padilla M, Enciso R. Local Anesthetic Injections for the Short-Term Treatment of Head and Neck Myofascial Pain Syndrome: A Systematic Review with Meta-Analysis. Journal of Oral & Facial Pain & Headache 2019;33(2)Lugo LH, Garca H, Rogers H, Plata JA. Treatment of myofascial pain syndrome with lidocaine injection and physical therapy, alone or in combination: a single blind, randomized, controlled clinical trial. BMC musculoskeletal disorders 2016;17(1):1-11Xie P, Qin B, Yang F, et al. Lidocaine Injection in the Intramuscular Innervation Zone Can Effectively Treat Chronic Neck Pain Caused by MTrPs in the Trapezius Muscle. Pain Physician 2015;18(5):E815-26Yilmaz O, Sivrikaya EC, Taskesen F, Pirpir C, Ciftci S. Comparison of the Efficacy of Botulinum Toxin, Local Anesthesia, and Platelet-Rich Plasma Injections in Patients With Myofascial Trigger Points in the Masseter Muscle. J Oral Maxillofac Surg 2021;79(1):88 e1-88 e9 doi: 10.1016/j.joms.2020.09.013[published Online First: Epub Date]|.Barad M, Ailani J, Hakim SM, Kissoon NR, Schuster NM. Percutaneous Interventional Strategies for Migraine Prevention: A Systematic Review and Practice Guideline. Pain Med 2022;23(1):164-88 doi: 10.1093/pm/pnab236[published Online First: Epub Date]|.Sabatke S, Scola RH, Paiva ES, Kowacs PA. Injection of trigger points in the temporal muscles of patients with miofascial syndrome. Arq Neuropsiquiatr 2015;73(10):861-6 doi: 10.1590/0004-282X20150135[published Online First: Epub Date]|.
Proposed LCD - Trigger Point Injections (TPI) (DL34211)
Karadas O, Inan LE, Ulas U, Odabasi Z. Efficacy of local lidocaine application on anxiety and depression and its curative effect on patients with chronic tension-type headache. Eur Neurol 2013;70(1-2):95-101 doi: 10.1159/000350619[published Online First: Epub Date]|.Baron EP, Cherian N, Tepper SJ. Role of greater occipital nerve blocks and trigger point injections for patients with dizziness and headache. Neurologist 2011;17(6):312-7 doi: 10.1097/NRL.0b013e318234e966[published Online First: Epub Date]|.Ashkenazi A, Blumenfeld A, Napchan U, et al. Peripheral nerve blocks and trigger point injections in headache management - a systematic review and suggestions for future research. Headache 2010;50(6):943-52 doi: 10.1111/j.1526-4610.2010.01675.x[published Online First: Epub Date]|.Venancio Rde A, Alencar FG, Jr., Zamperini C. Botulinum toxin, lidocaine, and dry-needling injections in patients with myofascial pain and headaches. Cranio 2009;27(1):46-53 doi: 10.1179/crn.2009.008[published Online First: Epub Date]|.Boelens OBA, Scheltinga MR, Houterman S, Roumen RM. Randomized clinical trial of trigger point infiltration with lidocaine to diagnose anterior cutaneous nerve entrapment syndrome. Br J Surg 2013;100(2):217-21 doi: 10.1002/bjs.8958[published Online First: Epub Date]|.Oor JE, Unlu C, Hazebroek EJ. A systematic review of the treatment for abdominal cutaneous nerve entrapment syndrome. Am J Surg 2016;212(1):165-74 doi: 10.1016/j.amjsurg.2015.12.013[published Online First: Epub Date]|.
Proposed LCD - Trigger Point Injections (TPI) (DL34211)
Boelens OB, Scheltinga MR, Houterman S, Roumen RM. Management of anterior cutaneous nerve entrapment syndrome in a cohort of 139 patients. Ann Surg 2011;254(6):1054-8 doi: 10.1097/SLA.0b013e31822d78b8[published Online First: Epub Date]|.Staal JB, de Bie RA, de Vet HC, Hildebrandt J, Nelemans P. Injection therapy for subacute and chronic low back pain: an updated Cochrane review. Spine (Phila Pa 1976) 2009;34(1):49-59 doi: 10.1097/BRS.0b013e3181909558[published Online First: Epub Date]|.Watters WC, 3rd, Resnick DK, Eck JC, et al. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 13: injection therapies, low-back pain, and lumbar fusion. J Neurosurg Spine 2014;21(1):79-90 doi: 10.3171/2014.4.SPINE14281[published Online First: Epub Date]|.Di Cesare A, Giombini A, Di Cesare M, Ripani M, Vulpiani MC, Saraceni VM. Comparison between the effects of trigger point mesotherapy versus acupuncture points mesotherapy in the treatment of chronic low back pain: a short term randomized controlled trial. Complement Ther Med 2011;19(1):19-26 doi: 10.1016/j.ctim.2010.11.002[published Online First: Epub Date]|.Kocak AO, Ahiskalioglu A, Sengun E, Gur STA, Akbas I. Comparison of intravenous NSAIDs and trigger point injection for low back pain in ED: A prospective randomized study. Am J Emerg Med 2019;37(10):1927-31 doi: 10.1016/j.ajem.2019.01.015[published Online First: Epub Date]|.
Proposed LCD - Trigger Point Injections (TPI) (DL34211)
Saeidian SR, Pipelzadeh MR, Rasras S, Zeinali M. Effect of trigger point injection on lumbosacral radiculopathy source. Anesth Pain Med 2014;4(4):e15500 doi: 10.5812/aapm.15500[published Online First: Epub Date]|.Khoshnazar SS, Farpour HR, Shahriarirad R. A comparison between effectiveness of gluteal trigger point and epidural steroid injection in lumbosacral canal stenosis patients: a randomized clinical trial. Br J Neurosurg 2022:1-7 doi: 10.1080/02688697.2022.2033698[published Online First: Epub Date]|.Chou R, Atlas S. Subacute and chronic low back pain: Nonsurgical interventional treatment. Secondary Subacute and chronic low back pain: Nonsurgical interventional treatment 2016.www.uptodate.com.Peloso PM, Khan M, Gross AR, et al. Pharmacological Interventions Including Medical Injections for Neck Pain: An Overview as Part of the ICON Project. 2013;7(Suppl 4):473-93 doi: 10.2174/1874325001307010473[published Online First: Epub Date]|.Freeman MD, Nystrom A, Centeno C. Chronic whiplash and central sensitization; an evaluation of the role of a myofascial trigger points in pain modulation. J Brachial Plex Peripher Nerve Inj 200923(4):2 doi: 10.1186/1749-7221-4-2.[published Online First: Epub Date]|.Staud R, Weyl E, Bartley E, Price D, Robinson M. Analgesic and anti-hyperalgesic effects of muscle injections with lidocaine or saline in patients with fibromyalgia syndrome. European Journal of Pain 2014;18(6):803-12
Proposed LCD - Trigger Point Injections (TPI) (DL34211)
Hong CZ, Hsueh TC. Difference in pain relief after trigger point injections in myofascial pain patients with and without fibromyalgia. Arch Phys Med Rehabil 1996;77(11):1161-6 doi: 10.1016/s0003-9993(96)90141-0[published Online First: Epub Date]|.Goldenberg DL, Burckhardt C, Crofford L. Management of fibromyalgia syndrome. JAMA 2004;292(19):2388-95 doi: 10.1001/jama.292.19.2388[published Online First: Epub Date]|.Scott NA, Guo B, Barton PM, Gerwin RD. Trigger point injections for chronic non-malignant musculoskeletal pain: a systematic review. Pain Medicine 2009;10(1):54-69Zoorob D, South M, Karram M, et al. A pilot randomized trial of levator injections versus physical therapy for treatment of pelvic floor myalgia and sexual pain. Int Urogynecol J 2015;26(6):845-52 doi: 10.1007/s00192-014-2606-4[published Online First: Epub Date]|.Patil S, Daniel G, Vyas R, et al. Neuromuscular treatment approach for women with chronic pelvic pain syndrome improving pelvic pain and functionality. Neurourol Urodyn 2022;41(1):220-28 doi: 10.1002/nau.24799[published Online First: Epub Date]|.Ratmansky M, Defrin R, Soroker N. A randomized controlled study of segmental neuromyotherapy for post-stroke hemiplegic shoulder pain. J Journal of rehabilitation medicine 2012;44(10):830-36Terlemez R, Ercalik T. Effect of piriformis injection on neuropathic pain. Agri 2019;31(4):178-82 doi: 10.14744/agri.2019.34735[published Online First: Epub Date]|.
Proposed LCD - Trigger Point Injections (TPI) (DL34211)
American Society of Anesthesiologists Task Force on Chronic Pain Management: Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology 2010;112(4):810-33Practice Guidelines for Chronic Pain Management: An Updated Report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine*. Anesthesiology 2010;112(4):810-33 doi: 10.1097/ALN.0b013e3181c43103[published Online First: Epub Date]|.Hegmann K TR, Anderson G etal. . ACOEM GUIDELINES: Invasive Treatments for Low Back Disorders. JOEM 2021;63(4):e215-e41NASS. Diagnosis and Treatment of Low Back Pain. Secondary Diagnosis and Treatment of Low Back Pain 2020.https://www.spine.org/.
Proposed LCD - Trigger Point Injections (TPI) (DL36859)
CMS National Coverage PolicyItalicizedfont represents CMS national language/wording copied directly from CMS Manuals or CMS Transmittals. Contractors are prohibited from changing national language/wording.Title XVIII of the Social Security Act, 1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Title XVIII of the Social Security Act, 1862(a)(1)(D) Investigational or ExperimentalIOM Citations:CMS IOM Publication 100-08,Medicare Program Integrity Manual,~ Chapter 13, 13.5.4 Reasonable and Necessary Provision in an LCDSocial Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.Code for Federal Regulations (CFR) References:CFR, Title 42, Ch. IV, 410.74 Physician assistant's services, 410.75 Nurse practitioner's services and 410.76 Clinical nurse specialist's services.NCDsNCD 30.3.3 Acupuncture for Chronic Low Back PainCoverage Indications, Limitations, and/or Medical NecessityInitial Trigger Point InjectionTrigger 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:There is a focal area of pain in the skeletal muscle.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 painANDThe 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 painANDNon-invasive conservative therapy is not successful as first line treatmentORmovement of a joint or limb is limited or blockedORthe TPI is necessary for diagnostic confirmation.
Proposed LCD - Trigger Point Injections (TPI) (DL36859)
Subsequent TPIRepeat Trigger point injections previously injected trigger points will be considered medically reasonable and necessary to treat myofascial pain syndrome when all of the following requirements are met: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-injectionANDConsistent pain relief from the most recent previous TPI lasting at least 6 weeks1ANDThe 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:
Proposed LCD - Trigger Point Injections (TPI) (DL36859)
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.There should be at least 6 weeks duration before TPI is repeated in the same location.Trigger point primary index pain must be measured prior to the injection at the beginning of the session.The post procedure pain level must be measured after the TPI at the conclusion of the session u sing the same scale* utilized at baseline.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.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 Provider should use established and measurable goals and objective scales to assess functionality and ADLs measures.Limitations:
Proposed LCD - Trigger Point Injections (TPI) (DL36859)
Limitations:A TPI involves the use of local anesthetic and does not include injections of biologicals (e.g., platelet rich plasma, stem cells, amniotic fluid, etc.) and/or any other injectates.It is not considered medically reasonable and necessary to perform TPI into multiple muscle groups in different anatomical regions during the same session.It is not considered medically reasonable and necessary to perform multiple blocks (ESI, sympathetic blocks, facet blocks, etc.) during the same session as TPI.Trigger point 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 should pain are considered investigational and therefore are not considered medically reasonable and necessary.Use of fluoroscopy or MRI guidance for performance of TPI is not considered reasonable and necessary.The use of ultrasound guidance for the performance of TPI is considered investigational.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.
Proposed LCD - Trigger Point Injections (TPI) (DL36859)
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 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.2All 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, and utilization of the required associated imaging modalities.General InformationAssociated InformationN/ASources of InformationN/ABibliography
Proposed LCD - Trigger Point Injections (TPI) (DL36859)
Manchikanti L, Singh V, Kloth D, et al. Interventional techniques in the management of chronic pain: Part 2. Pain Physician 2001;4(1):24Title XVIII of the Social Security Act: Sec. 1861.(s)(2) Part E-Miscellaneous Provisions: Definitions of Services I e. Secondary.https://www.ssa.gov/OP_Home/ssact/title18/1861.htm#ft495.Borg-Stein J, Stein J. Trigger points and tender points: one and the same? Does injection treatment help? Rheum Dis Clin North Am 1996;22(2):305-22 doi: 10.1016/s0889-857x(05)70274-x[published Online First: Epub Date]|.Fernndez-de-Las-Peas C, Dommerholt J. International consensus on diagnostic criteria and clinical considerations of myofascial trigger points: a Delphi study. Pain Medicine 2018;19(1):142-50Alvarez DJ, Rockwell PG. Trigger points: diagnosis and management. American family physician 2002;65(4):653Shankar H, Reddy S. Two-and three-dimensional ultrasound imaging to facilitate detection and targeting of taut bands in myofascial pain syndrome. Pain medicine 2012;13(7):971-75Ball A, Perreault T, Fernndez-de-Las-Peas C, Agnone M, Spennato J. Ultrasound Confirmation of the Multiple Loci Hypothesis of the Myofascial Trigger Point and the Diagnostic Importance of Specificity in the Elicitation of the Local Twitch Response. Diagnostics (Basel) 2022;12(2) doi: 10.3390/diagnostics12020321[published Online First: Epub Date]|.Lewis J, Tehan P. A blinded pilot study investigating the use of diagnostic ultrasound for detecting active myofascial trigger points. Pain 1999;79(1):39-44Rha D-w, Shin JC, Kim Y-K, Jung JH, Kim YU, Lee SC. Detecting local twitch responses of myofascial trigger points in the lower-back muscles using ultrasonography. Archives of physical medicine and rehabilitation 2011;92(10):1576-80. e1
Proposed LCD - Trigger Point Injections (TPI) (DL36859)
Sikdar S, Shah JP, Gebreab T, et al. Novel applications of ultrasound technology to visualize and characterize myofascial trigger points and surrounding soft tissue. Archives of physical medicine and rehabilitation 2009;90(11):1829-38Cojocaru MC, Cojocaru IM, Voiculescu VM, Cojan-Carlea NA, Dumitru VL, Berteanu M. Trigger pointsultrasound and thermal findings. J Med Life 2015;8(3):315-8Kang JJ, Kim J, Park S, Paek S, Kim TH, Kim DK. Feasibility of Ultrasound-Guided Trigger Point Injection in Patients with Myofascial Pain Syndrome. Healthcare (Basel) 2019;7(4) doi: 10.3390/healthcare7040118[published Online First: Epub Date]|.Botwin KP, Sharma K, Saliba R, Patel BC. Ultrasound-guided trigger point injections in the cervicothoracic musculature: a new and unreported technique. Pain Physician 2008;11(6):885-9Quintner JL, Bove GM, Cohen ML. A critical evaluation of the trigger point phenomenon. Rheumatology 2014;54(3):392-99 doi: 10.1093/rheumatology/keu471[published Online First: Epub Date]|.Shipton B, Sagar S, Mall JK. Trigger Point Management. Am Fam Physician 2023;107(2):159-64Ahmed S, Subramaniam S, Sidhu K, et al. Effect of Local Anesthetic Versus Botulinum Toxin-A Injections for Myofascial Pain Disorders: A Systematic Review and Meta-Analysis. Clin J Pain 2019;35(4):353-67 doi: 10.1097/AJP.0000000000000681[published Online First: Epub Date]|.