Title XVIII of the Social Security Act, §1862(a)(1)(A). Allows coverage and payment for only those services that are considered to be medically reasonable and necessary.

Title XVIII of the Social Security Act, §1833(e). Prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Myofascial trigger points are small, circumscribed, hyperirritable foci in muscles and fascia, often found with a firm or taut band of skeletal muscle.² These trigger points produce a referred pain patterned characteristic for that individual muscle. Each pattern becomes a single part of a single muscle syndrome. To successfully treat chronic myofascial pain syndrome (trigger points) each single muscle syndrome needs to be identified along with every perpetuating factor.

The pain of active trigger points can begin as an acute single muscle syndrome resulting from stress overload or injury to the muscle, or can develop slowly because of chronic or repetitive muscle strain. The pain normally refers distal to the specific hypersensitive trigger point. Trigger point injections are used to alleviate this pain.

There is no laboratory or imaging test for establishing the diagnosis of trigger points; it depends therefore upon the detailed history and thorough examination. The following diagnostic criteria are adopted by this A/B MAC from Simons.³

Major criteria. All four must be present to establish the diagnosis.

A. Regional pain complaint
B. Pain complaint or altered sensation in the expected distribution of referred pain from a trigger point
C. Taut band palpable in an accessible muscle with exquisite tenderness at one point along the length of it
D. Some degree of restricted range of motion, when measurable.

Minor criteria. Only one of four needed for the diagnosis.

A. Reproduction of referred pain pattern by stimulating the trigger point
B. Altered sensation by pressure on the tender spot
C. Local response elicited by snapping palpation at the tender spot or by needle insertion into the tender spot
D. Pain alleviated by stretching or injecting the tender Spot

The goal is to identify and treat the cause of the pain, not just the symptom. After making the diagnosis of myofascial pain syndrome and identifying the trigger point responsible for it, the treatment options are:

1. Medical management, which may include consultation with a specialist in pain medicine
2. Medical management that may include the use of analgesics and adjunctive medications, including anti-depressant medications, shown to be effective in the management of chronic pain conditions.
3. Passive physical therapy modalities, including "stretch and spray" heat and cold therapy, passive range of motion and deep muscle massage.
4. Active physical therapy, including active range of motion, exercise therapy and physical conditioning. Application of low intensity ultrasound directed at the trigger point (this approach is used when the trigger point is otherwise inaccessible).
5. Manipulation therapy.
6. Injection of local anesthetic, with or without corticosteroid, into the muscle trigger points.
7. a. as initial or the only therapy when a joint movement is impaired, such as when a muscle cannot be stretched fully or is in fixed position.
   
   b. as treatment of trigger points that are unresponsive to non-invasive methods of treatment, e.g., exercise, use of medications, stretch and spray.

The CPT codes for trigger point injections use the phrase "muscle group(s)". For the purpose of this policy, this A/B MAC defines "muscle group" as a group of muscles that are contiguous and that share a common function, e.g., flexion, stabilization or extension of a joint. Trigger points that exist in muscles that are widely separated anatomically and that have different functions may be considered to be in separate muscle groups.

To treat established trigger points, after identification, of the muscle or muscle group where the trigger point is located and documenting that in the patient's medical record.

Coverage is provided for injections which are medically necessary due to illness or injury and based on symptoms and signs. An injection of a trigger point is considered medically necessary when it is currently causing tenderness and/or weakness, restricting motion and/or causing referred pain when compressed.

Use of injections should be done as part of an overall management (usually short term) plan including one or more of the following:

1. Diagnostic evaluation to clearly identify the primary cause, if possible.
2. Physical and occupational therapy.
3. Psychiatric evaluation and therapy.
4. A trial of oral non-steroid analgesic/anti-inflammatory drugs, if not contraindicated.

Acupuncture is not a covered service, even if provided for treatment of an established trigger point.

Use of acupuncture needles and/or the passage of electrical current through these needles is not a covered service, whether the service is rendered by an acupuncturist or any other provider.

Providers of acupuncture services must inform the beneficiary that their services will not be covered as acupuncture is not a Medicare benefit.

Prolotherapy, the injection into a damaged tissue of an irritant to induce inflammation, is not covered by Medicare. Billing this under the trigger point injection codes is misrepresentation.

"Dry needling" of trigger points is a non-covered procedure since it is considered unproven and investigational.

Screening diagnoses will be denied as routine services.

Compliance with the provisions in this policy is subject to monitoring by post payment data analysis and subsequent medical review.

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