Trigger points are hyperirritable areas located in skeletal muscle. They produce pain locally and often accompany chronic musculoskeletal disorders. Trigger point injections are an effective treatment modality used to inactivate trigger points and provide prompt relief of symptoms.

Coverage is allowed for tendon sheath, ligament, or trigger point injections which are medically necessary based on specific symptoms, illness or injuries. Such injections will be covered when all of the following are present:

1. The patient’s clinical condition is marked by substantial pain and/or significant functional disability.
2. Other conservative therapy has not provided acceptable relief, is contraindicated, or not appropriate.
3. There is a reasonable likelihood that injection will significantly improve the patient’s pain and/or functional disability.

Services reported for conditions not addressed on this policy will be denied as not medically necessary.  A provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

Limitations

Trigger point injections used on a routine basis for patients with chronic non-malignant pain syndromes are not medically necessary and are not covered.

Only injections of local anesthetics, corticosteroids, and collagenase clostridium histolyticum for Dupuytren's contracture with a palpable cord are covered. Injections consisting of only saline and/or botanical substances are not supported in the peer-reviewed literature and are not covered.

Services performed for excessive frequency are not medically necessary. Frequency is considered excessive when services are performed more frequently than generally accepted by peers and the reason for additional services is not justified by documentation.

Tenosynovitis treatments should be of short duration (1-2 injections). Documentation in the medical record must support the medical necessity for additional injections.

Repeat trigger point injections may be necessary when there is evidence of persistent pain or inflammation. Generally more than three injections of the same trigger point are not indicated. Evidence of partial improvements to the range of motion in any muscle area after an injection would justify a repeat injection. The medical record must clearly reflect the medical necessity for repeated injections.

Documentation Requirements

The patient's medical record must document the medical necessity of services performed for each date of service submitted on a claim, and documentation must be available on request.

Documentation must be available in the patient’s medical record to support the medical necessity of frequent or prolonged injection regimens.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

The following coding guidelines from Article A34409 were removed as of 06/18/2011.

The following coding guidelines must be used in conjunction with the Trigger Point, Tendon Sheath Injections LCD:

• CPT code 20526 is to be used for therapeutic carpal tunnel syndrome injections. Use ICD-9 code 354.0.
• CPT codes 20550 and 20551 must not be used for joint injections. When used for injection of ligaments or tendon sheaths, use the ICD-9 codes that designate enthesopathy or tendonitis (e.g., 720.0; 726.0) or entrapment syndromes (e.g., 354.1-355.6).
• Systemic lupus and rheumatoid arthritis ICD-9 codes are not specific as to anatomic location and may be used for these services when tenosynovitis is present. Many of the other arthritides require 5th digits that specify joints and are therefore inappropriate for these services.
• CPT codes 20552 and 20553 are to be used for injection of trigger or tender points. Use ICD-9 codes for pain, spasm or fibromyositis (e.g., 728.85; 729.0-729.1). Submit the appropriate code and a quantity of one (1).

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no 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 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

Use of these codes does not guarantee reimbursement. The patient's medical record must document that the coverage criteria in this policy have been met.

Code 20526

Codes 20550 and 20551

Codes 20552 and 20553