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SUPERSEDED Local Coverage Determination (LCD)

Trigger Point Injections

L34211

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Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.
Superseded
To see the currently-in-effect version of this document, go to the section.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L34211
Original ICD-9 LCD ID
Not Applicable
LCD Title
Trigger Point Injections
Proposed LCD in Comment Period
N/A
Source Proposed LCD
DL34211
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 12/01/2019
Revision Ending Date
03/31/2024
Retirement Date
N/A
Notice Period Start Date
04/10/2017
Notice Period End Date
05/25/2017
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

Issue

Issue Description
Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

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.

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

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.
Summary of Evidence

N/A
Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
N/A
Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

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Group 1

Group 1 Paragraph

N/A

 Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

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Group 1

Group 1 Paragraph:

N/A

 Group 1 Codes:

N/A

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

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Group 1

Group 1 Paragraph:

N/A

 Group 1 Codes:

N/A

N/A

Additional ICD-10 Information

General Information

Associated Information

It is expected that trigger point injections would not usually be performed more often than three sessions in a three month period. If trigger point injections are performed more than three sessions in a three month period, the reason for repeated performance and the substances injected should be evident in the medical record and available to the Contractor upon request.

This contractor may request records when it is apparent that patients are requiring a significant number of injections to manage their pain.
Sources of Information

Local Medical Review Policy from Iowa, Aug 1999

  1. Manchikanti L, Singh V, Kloth D, et al. Interventional Techniques in the Management of Chronic Pain: Part 2.0. Pain Physician. 2001;4(1):24-96
  2. Simons DG. Muscular Pain Syndromes. In: JR Friction. Awad EA, JR. eds. Advances in Pain Research and Therapy. Lippincott-Raven. Philadelphia. 1990;17:1-41.
  3. Travell JG, Simons DG. Myofascial Pain and Dysfunction, The Trigger Point Manual. Baltimore. Lippincott Williams & Wilkins. 1983.

The following sources of information were cited in the Iowa LMRP:

  1. Other Carrier Policies (Kansas/Nebraska/Western Missouri, North Dakota, GHI of New York)
  2. Satterthwaite, Dollison. Handbook of Pain Management. Williams and Wilkins. 1994;2 ed
  3. Yale University School of Medicine, Department of Pain Management
  4. Connecticut Society of Anesthesiology
  5. Local Medical Policy from Nationwide Insurance Company
  6. Medicare Operations Spine Five: 1980;193-200.
  7. Journal of Neurosurgery. 1975;43:448-51.
Bibliography

N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
12/01/2019 R7

The LCD is revised to remove CPT/HCPCS codes in the Keyword Section of the LCD.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.
  • Other (The LCD is revised to remove CPT/HCPCS codes in the Keyword Section of the LCD.
    )
12/01/2019 R6

12/01/2019:At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

As required by CR 10901, all billing and coding information has been moved to the companion article, this article is linked to the LCD
  • Provider Education/Guidance
  • Revisions Due To Code Removal
10/01/2018 R5

09/28/2018: At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

Typographical error in revision history was corrected to read: Effective 10/1/2018, LCD is revised per the annual ICD-10-CM codes to add ICD-10-CM code M79.18
  • Typographical Error
10/01/2018 R4

08/30/2018: At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

Effective 10/1/2017, LCD is revised per the annual ICD-10-CM code update to:

Add ICD-10-CM codes: M79.18
  • Revisions Due To ICD-10-CM Code Changes
10/01/2017 R3

DATE (08/28/2017): At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

Effective 10/1/2017, LCD is revised per the annual ICD-10-CM code update to: Add ICD-10-CM codes: M53.83; M583.84; M53.85; M53.86; M53.87; M53.88
  • Revisions Due To ICD-10-CM Code Changes
10/01/2017 R2

DATE (08/28/2017): At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

Effective 10/1/2017, LCD is revised per the annual ICD-10-CM code update to: Add ICD-10-CM codes: M53.83; M583.84; M53.85; M53.86; M53.87; M53.88


 
  • Revisions Due To ICD-10-CM Code Changes
05/26/2017 R1 03/15/2017 - This LCD version was created as a result of DL34211 being released to a Final LCD for creation of uniform LCDs within a MAC Jurisdiction.
  • Creation of Uniform LCDs Within a MAC Jurisdiction
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Associated Documents

Attachments
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Related National Coverage Documents
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Public Versions
Updated On Effective Dates Status
04/02/2024 04/01/2024 - N/A Currently in Effect View
02/07/2024 04/01/2024 - N/A Superseded View
01/29/2020 12/01/2019 - 03/31/2024 Superseded You are here
11/07/2019 12/01/2019 - N/A Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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